Successful Disruption of Massive Calcified Nodules Using Novel Shockwave Intravascular Lithotripsy

A 74-year-old woman underwent coronary angiography showing severely calcified lesions in the ostial and mid-left circumflex artery (LCx) with patent graft to the left anterior descending artery and occluded graft to the LCx (Figure A). Even after multiple rotational atherectomies (RA) with a 1.5-mm burr (Figure a), optical coherence tomography (OCT) demonstrated almost unmodified massive calcified nodules (CN) in the ostium, with multiple intimal microdissections (Figure b–d). Accordingly, intravascular lithotripsy (IVL; Shockwave Medical, Fremont, CA, USA), which was introduced more recently as an alternative to atherectomy for the treatment of calcified coronary lesions, was performed using a 3.5×12-mm IVL balloon, in which 40 pulses were applied (Figure a’). OCT clearly showed disrupted CN with enlarged lumen; specifically, deep fractures were created on CN (Figure b’–d’). Finally, an excellent angiographic result was obtained with implantation of 2 drug-eluting stents followed by adequate post-dilatation (Figure B).

Figure.

Successful modification of calcified nodules (CN). (A) Initial angiography showing massive CN at the ostium of the left circumflex artery (red arrowheads). Even after (a) multiple rotational atherectomies (RA), (b) optical coherence tomography (OCT) showed undilated proximal lesion. (c,d) RA created multiple intimal microdissections (asterisks) but could not disrupt CN. (B) Final angiography showing excellent results. Following (a’) intravascular lithotripsy (IVL), (b’) OCT showed disrupted CN. (c’) IVL created deep fractures on CN (white arrows) and (d’) dilated the lumen successfully.

Consistent with previous reports, IVL can produce focal disruption to gain lumen area, even in the presence of circumferential deep calcification.¹ Of note, the present case has further demonstrated the effectiveness of the novel IVL technique on a massive CN, one of the hardest types of rock to treat.

Disclosures

The authors declare no conflicts of interest.

Reference

• 1.   Jurado-Román A, Gonzálvez A, Galeote G, Jiménez-Valero S, Moreno R. RotaTripsy: Combination of rotational atherectomy and intravascular lithotripsy for the treatment of severely calcified lesions. JACC Cardiovasc Interv 2019; 12: e127–e129.