We present a 71-year-old man with diabetes, hypertension, dyslipidemia, and bicuspid aortic stenosis post-TAVR (Boston Scientific Lotus Valve 25 mm) 9 years ago, with known valve degeneration and moderate stenosis (Figure 1). He also has a history of LM-LAD stenting with recurrent in-stent restenosis and presented with 1-month intermittent chest tightness. Physical exam revealed a systolic murmur over the aortic area.

His electrocardiography revealed sinus rhythm without significant ST-segment deviation (Figure 2). Laboratory data revealed fair hemoglobin (14.3 g/dL), creatinine (1.3 mg/dL) and LDL-cholesterol (61 mg/dL) but a significantly elevated lipoprotein(a) (116.8 mg/dL).

Diagnostic catheterization revealed a stationary trans-aortic valve peak-to-peak pressure gradient of 25 mmHg and a critical in-stent restenosis over proximal LAD (Figure 3). Other coronary arteries were patent. After a shared decision making, intravascular image (IVI)-guided percutaneous coronary intervention (PCI) was initiated.

The procedure began with left coronary artery engagement using a 6 Fr Terumo BL3.5 guiding catheter. A Runthrough floppy wire was advanced into the distal LAD, with a Sion wire placed in the left circumflex artery (LCX). Intravascular ultrasound (IVUS) of the LAD revealed fibrous plaque distal to the stent edge in the proximal LAD (Figure 4A), in-stent restenosis with neointimal proliferation and lipid-rich plaque (Figures 4B, 4C), and satisfactory LM stent status (Figure 4D). Angioplasty was performed on the proximal LAD using a Wolverine Coronary Cutting Balloon (3.5mm x 15mm) and NC balloon (3.5mm x 15mm). A distal edge dissection was noticed (Figure 5A, 5B), leading to the deployment of a drug-eluting stent (DES) (Elixir DESyne 2.5mm x 18mm). However, angiography showed decreased distal flow and a new lesion at the LAD-first diagonal artery (D1) bifurcation (Figure 5C, 5D). IVUS identified a hypoechoic lesion at the bifurcation (Figure 6A, 6B), likely distal embolization. Aspiration thrombectomy using the ELIMINATE Aspiration Catheter did not retrieve a thrombus. Kissing balloon technique was applied, showing improvement over bifurcation, with D1 flow remained reduced. A second thrombectomy yielded atheroma-like material (Figure 6C), with improved flow. Angioplasty of the in-stent restenosis was performed using a B.Braun DEB SeQuent Please (3.5mm x 30mm). Final angiography showed TIMI 3 flow without dissection (Figure 5E, 5F); the patient tolerated the procedure well.

We present a case of a gentleman with elevated lipoprotein(a) experiencing recurrent in-stent restenosis. During PCI, distal embolization was observed and managed with IVI and aspiration thrombectomy. Elevated lipoprotein(a) is a key risk factor for residual atherosclerotic cardiovascular disease (ASCVD) and aortic stenosis. Distal embolization during PCI can impair myocardial perfusion, causing no-reflow, and poor outcomes. This case underscores the importance of IVI in managing complex PCI, improving lesion identification, and providing ASCVD pathophysiology insights.