How should i treat recurrent restenosis with underexpanded multilayered struts after repeated complex bifurcation stenting?

BACKGROUND: A 68-year-old male, with a history of repeat percutaneous intervention for the treatment of severe calcific stenosis of the left circumflex artery and obtuse marginal branch bifurcation, presented with stable angina at a local hospital. He was found to have recurrent in-stent restenosis of this lesion and subsequently underwent a fifth reintervention; however, adequate balloon dilatation was not achievable in spite of non-compliant and cutting balloon use. In view of continuing symptoms despite optimal medical therapy, the patient was transferred to our hospital for further management. INVESTIGATION: Coronary angiography, intravascular ultrasound. DiAGNOSIS: Recurrent in-stent restenosis following prior repeat complex bifurcation stenting. MANAGEMENT: Rotational atherectomy of the multilayered stent struts, followed by successful balloon dilatation with a cutting balloon at high pressure, and treatment with a drug-coated balloon.