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Aims Patient male, 38 years old, affected by hypercholesterolaemia, carotid atherosclerosis, in 2014 NSTEMI (bivascular coronary artery disease treated by angioplasty and implantation of a medicated stent in the ostial and proximal tract of the right coronary artery). In September 2021 the patient went to the emergency room of our hospital for chest pain, that comes during physical exertion, with a spontaneous regression. We performed blood tests that showed phase rise of the Hs-TNI (&amp;gt;25 000 ng/dl). The ECG showed lateral sub-endocardial ischemia and the transthoracic echocardiogram a slight reduction in ejection fraction with hypochinesia of the inferior and inferior-lateral wall. After collegial discussion, it was decided to perform a coronary angiography. Methods and results The coronary angiography showed the left coronary artery free from stenosis, with a collateral circle towards the right coronary; the right coronary showed an ostial and proximal critical in-stent restenosis with patency of the stent in the middle segment, total occlusion of the distal segment. It was decided to treat the right coronary. A guide wire was pushed into to the right coronary with difficulty and, after recanalization of the vessel, an optical coherence tomography (OCT) was performed. The OCT pointed out a homogeneous widespread neointima into the stent and an extraluminal fibrous-calcified plaque in the ostial proximal segment, which caused likely the stent under-expansion and then the stent fracture. We proceeded with angioplasty and stent implantation of the distal lesion. Due to the mechanism underlying critical in-stent restenosis (fracture of the stent) of the ostial proximal segment, we first proceed with a pre-dilatation of the lesion and then with a stent in stent implantation. Post-dilatation with a non-compliant balloon at high atm. Eventually, we found out a detail not visible before due to the ostial stenosis: the protrusion of some millimeters of the previously implanted stent in the ascending aorta; this was the cause of the difficulty in advancing the angioplasty material throughout the procedure. As a result, we had no complications. Conclusions Intracoronary imaging has stronger evidences to guide the percutaneous revascularization, especially for in-stent restenosis. Evaluation by OCT can highlight the mechanism of in-stent restenosis (biological causes/mechanical causes) and consequently it can guide the most appropriate method to perform percutaneous revascularization.

712 In-stent restenosis: how optical coherence tomography can make the difference