Excimer Laser for Calcified Nodule-Driven Early Stent Failure

BACKGROUND: In-stent restenosis (ISR) in hemodialysis patients is frequently driven by calcified nodules. The role of excimer laser coronary atherectomy (ELCA) in disrupting peristent calcification remains under-recognized. CASE SUMMARY: An 81-year-old man on hemodialysis underwent primary percutaneous coronary intervention for ST-segment elevation myocardial infarction involving the ostial right coronary artery. Three months later, angiography revealed subocclusive ISR. Intravascular ultrasound demonstrated a protruding calcified plaque flap suggestive of calcified nodule reprotrusion. ELCA using a 1.4-mm catheter resulted in fragmentation of the protruding calcified tissue and disruption of peristent calcium. DISCUSSION: Despite transient contrast staining, 6-month angiography and optical coherence tomography demonstrated durable patency and stable tissue healing. CONCLUSION: ELCA may be an effective adjunctive strategy for structurally driven ISR caused by calcified nodule reprotrusion. TAKE-HOME MESSAGES: Early ISR in hemodialysis patients may be structurally driven by recurrent calcified nodule protrusion through the stent struts rather than neointimal proliferation. ELCA can facilitate luminal gain through fragmentation of protruding calcified nodules and photomechanical disruption of peristent calcium.