[The modified hugging balloon technique]

Percutaneous coronary intervention has revolutionized the management of coronary artery disease, yet in-stent restenosis (ISR) remains a clinical challenge, especially when complicated by calcification. Various techniques are available for the modification of calcified ISR, including super-high-pressure balloon dilation, in-stent rotational atherectomy, excimer laser coronary atherectomy and intravascular lithotripsy (IVL). This case report presents a challenging scenario of very late calcified ISR in a large coronary artery, highlighting diagnostic and interventional considerations. A patient with a history of multiple cardiovascular risk factors presented with infero-lateral ST-elevation myocardial infarction. Coronary angiography revealed severe very late ISR in the distal right coronary artery. Despite initial interventions, severe stent under-expansion persisted due to extensive calcification. The operator employed shockwave lithotripsy alongside a non-compliant balloon to achieve the vessel diameter and an optimal stent expansion. While the evidence for some interventions is limited, case series and registries suggest promising outcomes with IVL, particularly in refractory cases. Our proposed approach addresses the limitations posed by vessel diameter, demonstrating potential efficacy in this challenging case. This case report emphasizes the need for tailored therapeutic strategies and the integration of innovative techniques in managing calcified ISR, with IVL emerging as a promising option in selected cases.