Thepatient is an 81-year-old male with type 2 diabetes mellitus, hypertension, andend-stage renal disease on dialysis. He has ischemic cardiomyopathy with EF 30%and a history of CABG (LITA-LAD, RITA-RCA-LCX) 20 years ago. A Bare metal stent(3.0/24mm) was implanted 15 years ago for native RCA due to RITA obstruction. Inthis time, he was hospitalized for worsening heart failure, and after the heartfailure improved, CAG revealed that the native RCA was completely occluded fromthe orifice. 

He had a chronic dissection of the abdominal aorta and a 6Fr guide catheter JR4.0 was placed in the RCA via the right brachial artery. Sequential balloon dilatation was performed with 2.0mm and 2.75mm cutting balloons, but the restenosis lesion in the stent was highly calcified and indentations did not improve even with a 2.75mm NC balloon at 24 atm. Debulking was deemed necessary and PCI was performed on another day. A 7Fr guide catheter AL0.75 was placed in the RCA via the right brachial artery. 14 times of rotational atherectomy at 210,000 rpm with a 1.5mm bar were performed in ISR lesions. A 3.0 mm scoring balloon was used for additional dilation to 22atm. IVUS showed that the calcification had faded, and the small fractures of the calcification were made. The EES 3.5/48mm and 4.0/18mm were overlapped and implanted. Good dilation and crimping were confirmed by IVUS, and the procedure was completed.

Highly calcified coronary lesions and restenosis are common and poor stent dilatation can lead to restenosis. Plaque modification prior to stent implantation is particularly important in dialysis patients. In this case, when neointimal calcification due to in-stent restenosis was evident, gentle rotational atherectomy with high-speed rotation was effective and the stent was successfully expanded and implanted.