A review of the pathogenic mechanism and clinical management progress of in-stent calcification restenosis

Calcific in-stent restenosis (ISR) is a challenging complication of coronary percutaneous coronary intervention (PCI) that severely impairs long-term prognosis. Calcified lesions restrict stent expansion and exacerbate neointimal hyperplasia and neoatherosclerosis, thereby increasing the risk of ISR. Recent advances in interventional and imaging technologies have deepened insights into its molecular mechanisms, biomechanical disorders, inflammatory responses, and calcification morphology-related risks. High-resolution intravascular imaging (OCT/IVUS) enables precise evaluation of calcification characteristics, while novel therapies including intravascular lithotripsy (IVL), orbital atherectomy, and hybrid ablation strategies have revolutionized the management of coronary calcified ISR. This review systematically summarizes the pathophysiological mechanisms, imaging evaluation, and advances in the clinical management of coronary in-stent calcific restenosis, proposes a clinical treatment algorithm, and outlines future research directions, aiming to provide evidence-based guidance for clinical practice.