Efficacy of Novel Intravascular Lithoplasty for a Tortuous and Severely Calcified Coronary Lesion Unsuccessfully Treated With Rotational Atherectomy

A 72-year-old woman with diabetes and a 17-year history of dialysis was hospitalized for angina pectoris. Coronary angiography (CAG) and computed tomography revealed a heavily calcified stenosis in the proximal right coronary artery (RCA) (Figure A1,A2). We decided to perform rotational atherectomy (RA); however, the 1.5-mm burr failed to pass the lesion due to heavy calcification and steep vessel angulation (Figure A3). When the burr became entrapped, the driveshaft fractured and separated (Figure A4). After retrieving the burr and driveshaft with a snare, we re-attempted RA with 1.5- and 2.0-mm burrs, which also failed to pass through the lesion and the driveshafts broke, as with the first burr. Because the lesion could not be adequately predilated with a scoring balloon (3.0/15 mm) (Figure A5), the procedure was suboptimally terminated with a drug-coated balloon (3.5/20 mm) (Figure A6).

Figure.

(A1) Initial coronary angiography (CAG). (A2) Computed tomography. (A3) Entrapped burr. (A4) Fractured and separated driveshaft. (A5) Failure to fully dilate the lesion with a scoring balloon. (A6) Final CAG 5 months earlier. (B1) CAG on readmission. (B2) Optical coherence tomography (OCT) before intravascular lithoplasty (IVL). (B3,B4) CAG and OCT after IVL. (C1) Complete expansion of the scoring balloon. (C2) Final CAG.

She was re-admitted 5 months later for angina pectoris and CAG showed restenosis in the proximal RCA (Figure B1). Optical coherence tomography (OCT) revealed nearly circumferential calcification (Figure B2; Supplementary Movie 1). An intravascular lithoplasty (IVL) balloon (Shockwave, 4.0/12 mm) was inflated to 4 and 6 atm with 80 pulses of ultrasound energy. After IVL, OCT demonstrated multiple cracks in the calcified lesion and discontinuous areas of calcification (Figure B3,B4; Supplementary Movie 2). After additional predilatation with a scoring balloon (3.25/10 mm) (Figure C1), we successfully implanted a drug-eluting stent (4.0/24 mm) (Figure C2). There was no restenosis at the 6-month follow-up CAG.

RA is sometimes not suitable for tortuous lesions. IVL emits pulses circumferentially and modifies calcified tissues by creating microfractures despite low balloon pressure. The effect is independent of guidewire bias. This is the first report showing that IVL is safe and feasible for angulated, heavily calcified lesions that a RA system cannot pass.

Disclosures

None.

Supplementary Files

Supplementary Movie 1. OCT before IVL.

Supplementary Movie 2. OCT after IVL.

Please find supplementary file(s);

https://doi.org/10.1253/circj.CJ-22-0759