A case of in-stent restenosis due to mechanical compression caused by the protrusion of calcified nodules successfully treated with a Jetstream™ atherectomy system followed by a drug-coated balloon angioplasty

A 70-year-old man with hypertension, dyslipidemia, and coronary artery disease was admitted to the hospital due to recurrent intermittent claudication and an ankle–brachial index was 0.50 on the left side, indicating in-stent restenosis (ISR) of the superficial femoral artery (SFA), as documented by duplex ultrasound. Initial angiography revealed 90% ISR in the middle segment of the SFA (Fig. 1A), and intravascular ultrasound (IVUS) confirmed that the ISR was caused by mechanical compression of calcified nodules protruding from the plaque outside the stent (Fig. 1B, C). To address this issue, we used a novel technique involving intentional penetration of the calcified nodules outside the stent with a CTO wire (Jupiter™ DP60 Peripheral Guidewire; Boston Scientific, Natick, MA, USA) directed by a Judkins right diagnostic catheter (Fig. 1D). We then successfully passed the wire from outside to inside the stent, traversing the intraplaque area and reaching the true lumen, as confirmed by IVUS (Fig. 1E, H). We used the Jetstream atherectomy system (Boston Scientific) to remove the calcified plaque, achieving partial penetration limited to the proximal stent struts (Fig. 1F, H; Supplementary-information), subsequently performed balloon dilation with a non-compliant balloon followed by drug-coated balloon angioplasty (Fig. 1I, J). The patient’s symptoms significantly improved postoperatively, and he was discharged on the second day without any perioperative complications. Several studies have reported that external mechanical forces acting on calcified plaques can result in the development of calcified nodules [1], which may cause in-stent restenosis by compressing the lumen [2, 3]. This innovative detour strategy may not be universally applicable, yet it presents an attractive alternative to traditional intra-arterial angioplasty for the treatment of ISR due to mechanical compression caused by the protrusion of calcified nodules.

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