Case Report Undilatable Stent Neoatherosclerosis Treated with Ad Hoc Rotational Atherectomy Michael Koutouzis, 1 Maria Agelaki, 1 Christos Maniotis, 1 Ioannis Tsiafoutis, 1 Vasileios Patris, 2 and Mihalis Argyriou 2 1 Cardiology Department, Hellenic Red Cross Hospital of Athens, Athens, Greece 2 Cardiac Surgery Department, Evaggelismos General Hospital, Athens, Greece Correspondence should be addressed to Maria Agelaki; magelaki@gmail.com Received 5 July 2016; Accepted 10 November 2016; Published 10 January 2017 Academic Editor: Nurten Sayar Copyright © 2017 Michael Koutouzis et al. Tis is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. A middle age woman with known ischemic heart disease and old stents in proximal lef anterior descending coronary artery (LAD) was admitted to Coronary Care Unit with acute coronary syndrome. Te coronary angiography showed one vessel disease with signifcant restenosis within the previously implanted stents. Te lesion was tough and remained undilatable despite high pressure balloon infation. Eventually, the balloon ruptured creating a massive dissection of the LAD beginning immediately afer the distal part of the undilatable lesion. We proceeded with a challenging ad hoc rotational atherectomy of the lesion and fnally stenting of the lesion. In-stent restenosis many years afer stent implantation is considered to be mainly due to neoatheromatosis compared to intimal hyperplasia, making lesion treatment more difcult and unpredictable. 1. Introduction In-stent stenosis long time afer initial stent implantation is not an uncommon fnding in our days, but treatment of this type of lesion, especially under unstable conditions, remains a challenge. Our recent knowledge about the histology of these lesions, being comprised mainly of neoatheroma and not neointima hyperplasia, explains the need for diferent management approach and the high rate of serious compli- cations, like dissection. 2. Case A 55-year-old female with a known history of ischemic heart disease, hypertension, dyslipidemia, and insulin dependent diabetes mellitus presented to the Accident and Emergency Department of our hospital with new onset chest pain. Te patient had a successful percutaneous coronary intervention in the proximal part of LAD for stable angina 9 years ago and two drug eluting stents (DES) (Taxus Liberte, Boston Scientifc) were uneventfully implanted then. On admis- sion, the electrocardiogram showed no signifcant changes and the cardiac troponin was slightly elevated. Te patient was admitted to the Cardiac Intensive Care unit with the diagnosis of non-ST elevation myocardial infarction. Te initial cardiac ultrasound showed normal ejection fraction with no regional wall motion abnormalities and no valvular abnormalities. Te patient remained symptomatic with chest pain recurrences afer maximum antianginal treatment with intravenous nitroglycerin and b-blockers, so we decided to proceed to emergency coronary angiography. Te coronary angiography was performed through the right radial approach afer placement of a 6 Fr radial sheath (KDL, China) and it showed one vessel disease with sig- nifcant restenosis within the previously implanted stents (Figure 1(a)). We decided to proceed to ad hoc percutaneous coronary intervention within the restenotic proximal LAD lesion. Te patient was loaded with 60 mg prasugrel in addi- tion to the already taken aspirin and intravenous bivalirudin was administered for anticoagulation at 0.75 mg/kg bolus Hindawi Publishing Corporation Case Reports in Cardiology Volume 2017, Article ID 3168067, 3 pages http://dx.doi.org/10.1155/2017/3168067