Precision Percutaneous Coronary Intervention of a Complex Lesion

Abstract

Background: Balloon dilation and atherectomy have several limitations in the treatment of heavily calcific coronary lesions.

Introduction: Intravascular lithotripsy (IVL) is a state-of-the-art system that modifies severe calcific coronary plaques efficiently. In this paper, we report our experience with IVL in the context of a calcific in-stent chronic total occlusion.

Case summary: A 75-year-old gentleman whose status was post percutaneous coronary intervention, with the deployment of two overlapping bare-metal stents in the mid-left anterior descending artery (LAD) 20 years ago, was admitted to our cardiac center for the elective intervention of in-stent chronic total occlusion (CTO) of LAD, which was performed using an antegrade wire escalation (AWE) technique. After recanalization of the CTO body, optical coherence tomography pullback confirmed a very high calcium score. Balloon dilatation attempts failed, so we proceeded with shockwave lithotripsy with successful full expansion of the 3.5-mm IVL balloon followed by a straightforward stent delivery. The procedure was complicated by distal wire perforation, which was handled in a timely manner with coil embolization. The patient's postoperative course was uneventful.

Conclusion: This case illustrates the feasibility and effectiveness of IVL that powerfully cracks coronary calcium while minimizing vessel wall trauma in the context of heavily calcific in-stent CTO. In our case, coronary perforation occurred in a small-caliber side branch, which was identified in a timely manner before hemodynamic compromise and treated successfully straight away with coil embolization.

Keywords: Optical coherence tomography; case report; chronic total occlusion; in-stent restenosis; percutaneous coronary intervention; shockwave lithotripsy.