Laser-Assisted OPN Technique for Recalcitrant Multilayer In-Stent Restenosis

BACKGROUND: Multilayer in-stent restenosis (ISR) with severe stent underexpansion represents a challenging clinical scenario with limited effective treatment options when conventional interventions fail, despite all our current advances in interventional cardiology. CASE SUMMARY: ). The procedure was completed with drug-eluting balloon therapy and ostial stenting. DISCUSSION: This case illustrates the systematic L-OPN approach for treating complex multilayer ISR when conventional methods have failed. Contrast-enhanced ELCA generates rapidly expanding microbubbles creating acoustic pressures that can disrupt calcified and fibrotic tissue surrounding underexpanded stents, facilitating subsequent balloon expansion. Intravascular ultrasound guidance was critical for assessing baseline underexpansion and confirming an adequate final result. TAKE-HOME MESSAGE: When conventional balloon angioplasty and intravascular lithotripsy fail to achieve adequate stent expansion in multilayer ISR, the combination of contrast-enhanced ELCA followed by OPN super-high-pressure balloon (L-OPN technique) guided by intravascular imaging offers a viable therapeutic option.