Vol 29, No 3 (2022)
Image in Cardiovascular Medicine
Published online: 2022-05-31

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Shockwave intracoronary lithotripsy for the treatment of calcium-mediated undilatable in-stent restenosis

Michał Kuzemczak12, Tomasz Pawłowski1, Robert Gil1
Pubmed: 35652139
Cardiol J 2022;29(3):521-522.

Abstract

Not available

IMAGE IN CARDIOVASCULAR MEDICINE

interventionAL CARDIOLOGY

Cardiology Journal 2022, Vol. 29, No. 3, 521–522

DOI: 10.5603/CJ.2022.0039 Copyright © 2022 Via Medica

ISSN 1897–5593 eISSN 1898018X

Shockwave intracoronary lithotripsy for the treatment of calcium-mediated undilatable in-stent restenosis

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Michał Kuzemczak12Tomasz Pawłowski1Robert Gil1
1Department of Invasive Cardiology, Central Clinical Hospital of the Ministry of Interior and Administration, Warsaw, Poland
2Chair of Emergency Medicine, Department of Medical Rescue, Poznan University of Medical Sciences, Poznan, Poland

Address for correspondence: Michał Kuzemczak, MD, PhD, MSc, Department of Invasive Cardiology, Central Clinical Hospital of the Ministry of Interior and Administration, ul. Wołoska 137, 02–507 Warszawa, Poland, tel: +48 698 020 284, e-mail: michal.kuzemczak@gmail.com

Received: 27.09.2021 Accepted: 6.02.2022

This article is available in open access under Creative Common Attribution-Non-Commercial-No Derivatives 4.0 International (CC BY-NC-ND 4.0) license, allowing to download articles and share them with others as long as they credit the authors and the publisher, but without permission to change them in any way or use them commercially.

Stent underexpansion due to calcifications is a predictor of stent failure and adverse clinical outcomes. Intravasular lithotripsy (IVL) has proved to be effective in dilating calcified de novo coronary lesions, but indications for the technique are expanding.

A 56-year-old man was scheduled for percutaneous coronary intervention due to severely calcified in-stent restenosis (ISR) in a bifurcation dedicated drug-eluting stent (DES) BiossLimC 3.5/4.25/24 mm which had been implanted 2 years prior into the left main/left anterior descending artery (LM/LAD) with a suboptimal result (residual stenosis of 50% in the proxLAD due to calcificatitons). As confimed during the present admission, the lesion progressed (90% calcified ISR) (Fig. 1A) and was unsuccessfully dilated with non-compliant balloon (NCB) inflations (Fig. 1B). Advancement of intavascular ultrasound catheter to interrogate the lesion was unsuccessful. Considering the presence of severe calcifications, calcium deposits covered by the previously implanted stent and angiographically visible calcifications in the outer layers of the vessel, we elected to use IVL. IVL balloon (Shockwave 3.5/12 mm) was positioned and inflated within the lesion in the proxLAD (4 atm).Then, 80 shockwave pulses were delivered with a subsequent pressure increase (6 atm). The “dog--boning“ effect (Fig. 1B) which had been observed during NCB inflations dissapeared (Fig. 1C) and the lesion was re-dilated with NCBs (NC Emerge 3.5/12 mm, Pantera Leo 3.75/12 mm). Subsequently, DES (Orsiro 3.5/13 mm) was implanted (Fig. 1D) and post-dilated with a NCB (Pantera Leo 3.75/ /12 mm). A satisfactory angiographic result was achieved (Fig. 1E) with good expansion/apposition of the stent, and achievement of Kang’s criteria (Fig. 1F).

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Figure 1. Procedural steps of the procedure; A. A baseline left coronary angiograpy demonstrating calcified in-stent restenosis in the ostium of the left anterior descending artery (LAD); B. Predilatation of the target lesion with a non--compliant balloon with a “dog-boning“ effect; C. An inflated intravasular lithotripsy balloon demonstrating lack of “dog-boning“ effect following 80 shockwave pulses; D. Stent implantation in the proxLAD; E. Final angiographic result; F. Final intavascular ultrasound assessment (lumen area 7.4 mm2).

The present case implies that IVL is an effective modality for undilatable ISR caused by stent underexpansion secondary to calcifications.

Conflict of interest: None declared