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case_images: Coronary angiography and intracoronary images of in-stent restenosis. Coronary angiography: (A) initial, (D) post-first excimer laser coronary atherectomy, (F) post-second excimer laser coronary atherectomy, and (I) final. (B) Initial intravascular ultrasound shows a large burden of low echogenic neointima. (C) Initial optical coherence tomography reveals that in-stent restenosis has low-attenuation signal tissue with invisible stent-struts and a small cavity (white arrows), suggestive of neoatherosclerosis rupture. A comparison of the optical coherence tomography images (E) after the first excimer laser coronary atherectomy and (G) after the second excimer laser coronary atherectomy. (H) Intravascular ultrasound images after the second excimer laser coronary atherectomy. After the second excimer laser coronary atherectomy, organized thrombi are observed within the in-stent restenosis lesion (yellow arrowheads). The green arrows show the effective vaporization by excimer laser coronary atherectomy.
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case_images: As non-ST-segment elevation myocardial infarction was suspected based on these findings, emergency CAG via the right radial artery was performed, which revealed proximal LAD-ISR and intermediate stenosis in the mid-left circumflex artery (Figure 1A). Intravascular ultrasound (IVUS) showed a large burden of low-echogenic neointima (Figure 1B). Subsequent optical coherence tomography (OCT) revealed low-attenuation signal tissues with invisible stent struts and a small ulcer (Figure 1C). Optical coherence tomography revealed that the neoatherosclerosis volume had reduced and soft tissue compatible with the thrombus emerged at the distal part of the culprit lesion (Figure 1D  and  E). Optical coherence tomography revealed a further effective vaporization of neoatherosclerosis and an apparent reduction in soft tissue volume (Figure 1F-H). Sufficient luminal gain was obtained without any coronary flow disturbance; therefore, a 3.5 mm drug-coated balloon (DCB) angioplasty was performed (Figure 1I). Myocardial perfusion scintigraphy 1 month later showed no significant ischaemia (see Supplementary material online, Figure S1).
case_images: Final optical coherence tomography and intravascular ultrasound images. The final (A) optical coherence tomography and (B) intravascular ultrasound images reveal sufficient lumen gain in the in-stent restenosis lesion after the percutaneous coronary intervention with excimer laser coronary atherectomy under distal protection. Each image corresponds to (i) through (iv) in Figure 1.
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case_images: In addition, final OCT/IVUS images revealed sufficient lumen gain in the ISR lesion (Figure 2).
case_images: Histopathological evaluation of trapped debris after excimer laser coronary atherectomy. (A) Debris trapped by an embolic protection device. (B-D) Histopathological evaluation of trapped debris with (B) haematoxylin-eosin staining, (C) phosphotungstic-acid haematoxylin staining, and (D) Factor VIII immunostaining. The debris is composed of organized white thrombi consisting of fibrin and platelet aggregation.
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case_images: A post hoc histopathological evaluation of the distally embolized debris trapped in the embolic protection device with haematoxylin-eosin staining, phosphotungstic acid haematoxylin staining, and immunostaining of Factor VIII, revealed organized white thrombi consisting of fibrin and platelet aggregation (Figure 3).