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Intravascular lithotripsy for the treatment of a heavily calcified recurrent in-stent restenosis in a patient with chronic coronary syndrome

Piotr Szolc1, 2, Bartłomiej Guzik1, 2, Łukasz Wiewiórka1, 2, Łukasz Niewiara1, 2, Paweł Kleczyński1, 2, Jacek Legutko1, 2

1Clinical Department of Interventional Cardiology, John Paul II Hospital, Kraków, Poland

2Department of Interventional Cardiology, Faculty of Medicine, Institute of Cardiology, Jagiellonian University Medical College, Kraków, Poland

We present a case of a 67-year-old male patient admitted to our Department due to recurrence of angina class II according to the Canadian Cardiovascular Society scale. The past medi­cal history included primary percutaneous coronary intervention (PCI) of the left anterior descending artery (LAD) with a bare-metal stent in 2005 and repeated PCI of the LAD with a sirolimus-eluting stent for in-stent restenosis (ISR) in 2007. Coronary angiography, fluoroscopic digital stent enhancement (DSE), and intravascular ultrasound revealed recurrence of ISR in the proximal segment of the LAD caused by stent under-expansion and heavily calcified neoatherosclerosis (Figure 1A, 1C). Physiology lesion assessment confirmed ischemia (resting full-cycle ratio 0.69 and fractional flow reserve 0.70) (Figure 1B). The patient refused minimally invasive direct coronary artery bypass grafting but agreed to high-risk repeated PCI. A transradial approach with a 6 F extra-back-up guiding catheter was chosen. Several attempts of lesion predilatation with a non-compliant balloon (NCB) and cutting balloon were ineffective. A very-high-pressure non-compliant balloon deployed at 48 atmospheres did not fully open (Figure 1D). Finally, we performed successful intravascular lithotripsy (IVL) using 3.0 × 12 mm IVL balloon catheter (Shockwave Medical, Fremont, CA, USA), which fully expanded at 4 atmospheres. After application of 80 pulses of ultrasound energy, full balloon expansion was achieved (Figure 1E).

New-generation sirolimus-eluting stent was implanted (3.5 × 48 mm) at 18 atm with subsequent NCB optimization. Control angiography showed optimal PCI result with <10% residual diameter stenosis and excellent stent expansion confirmed by DSE (Figure 1F). No complications occurred during the hospital stay, and the patient was discharged home 2 days after PCI with no symptoms of angina.

Adequate preparation of diffuse, heavily calcified in-stent neoatherosclerosis for stent implantation remains a challenge. In our case several attempts of lesion predilatation with NCB and cutting balloon, or even super-high-pressure NCB, were unsuccessful — no balloon fully expanded. Rotational atherectomy is another option, however, it usually requires the use of a large-size burr (≥2.0 mm), which significantly increases procedural risk [1]. Coronary laser atherectomy could be an option; yet, it is not widely available. Therefore, we decided to use a novel method of calcified lesion preparation for stent implantation — IVL [2]. The effectiveness of IVL has been already described in the primary treatment of severely calcified native coronary lesions [2, 3]. There is a single published case report describing off-label IVL application to treat calcified in-stent neoatherosclerosis as an adjunct to rotational atherectomy [4]. Salazar et al. reported successful IVL application as treatment of recurrent, calcified in-stent atherosclerosis in a diagonal branch [5]. We report for the first time a direct application of IVL to treat ISR caused by 13-year-old neoatherosclerosis in the previously double stented lesion in the proximal LAD. This represents a new, extremely promising, and easy-to-use treatment strategy (without a learning curve) for this high-risk lesion subset. However, its short-time safety and long-time effectiveness need to be proven in large-scale clinical trials.

Article information

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