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A 62-year-old man with a history of ischemic heart disease and dyslipidemia presented with aggravating effort angina. He underwent stent implantation with a 3.0 × 40 mm sirolimus-eluting stent at the mid portion of left anterior descending artery 2 years prior, but a heavily calcified lesion led to severe stent underexpansion, which did not resolve despite postdilation with a non-compliant (NC) balloon (Suppl. Video 1). Angiography demonstrated aggravated luminal narrowing in the underexpanded stent site (Fig. 1A, Suppl. Video 2); therefore, stent ablation with rotational atherectomy was planned. Pre-interventional optical coherence tomography (OCT) demonstrated that the diameter of the underexpanded stent was between 1.24 and 1.66 mm (Fig. 1B, C, Suppl. Video 3), which was also confirmed on three-dimensional OCT (Fig. 1D). OCT assessment led to stent ablation using a stepwise increase in burr size, from 1.25 mm to 1.50 mm and finally 1.75 mm. Following stent ablation, OCT showed no visible strut area in the site of the previously underexpanded stent (Fig. 1E, F). However, a minimal lumen area of 2.27 mm led to the performance of drug-coated balloon angioplasty with a 3.0 × 20 mm Pantera Lux (Biotronik, Bülach, Switzerland) after balloon dilation with a 3.0 × 15 mm NC balloon at 24 atm. Final angiography showed good distal flow without residual stenosis (Fig. 1G, Suppl. Video 4). This report highlights the superior resolution of OCT, which can aid in choosing the optimal burr size, and presents OCT images of successful stent ablation.

Successful optical coherence tomography-guided stent ablation with rotational atherectomy for an underexpanded stent