Author + information
- Received November 14, 2018
- Revision received December 9, 2018
- Accepted December 13, 2018
- Published online March 4, 2019.
- Fernando Alfonso, MD∗ (, )
- Teresa Bastante, MD,
- Paula Antuña, MD,
- Francisco de la Cuerda, MD,
- Javier Cuesta, MD,
- Marcos García-Guimaraes, MD and
- Fernando Rivero, MD
- ↵∗Address for correspondence:
Dr. Fernando Alfonso, Department of Cardiology, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria, IIS-IP, Universidad Autónoma de Madrid, c/ Diego de León 62, Madrid 28006, Spain.
A 63-year-old man presented with an acute coronary syndrome 15 years after revascularization of the left anterior descending coronary artery with 2 bare-metal stents. Coronary angiography revealed a severe, heavily calcified, lesion in a large obtuse marginal branch (Figure 1A) and diffuse in-stent restenosis in the left anterior descending coronary artery. Ad hoc treatment of the obtuse marginal branch proved to be unsuccessful because of an undilatable lesion. Several conventional and noncompliant balloons at very high-pressure (24 bar), and 2 different scoring balloons advanced through an extension catheter, failed to dilate the lesion that always caused a major waist (Figure 1B). The next day, coronary lithoplasty (Shockwave Medical, Fremont, California) was used to readily dilate the lesion using a 3.0-mm balloon at 4 bar delivering 20 pulses. Optical coherence tomography (OCT) demonstrated circumferential (“napkin-ring”) thick calcified sheets with multiple deep fractures (Figures 2A to 2D). Then, a drug-eluting stent could be easily implanted and post-dilated with a 3.0-mm noncompliant balloon at 18 atm with excellent angiographic and OCT result (Figures 1C and 2E to 2H). The stent in the left anterior descending coronary artery appeared underexpanded on angiography (Figure 1D). OCT revealed uniform neointimal proliferation (minimal lumen area 1.2 mm2) and confirmed severe stent underexpansion at various sites as a result of large calcified sheets (Figures 3A to 3C). Pre-dilation with a 2.5-mm noncompliant balloon showed a waist at 18 bar (Figure 1E). A 2.5-mm lithoplasty balloon was used to sequentially deliver 20 pulses at different locations along the stent (80 pulses in total). Subsequently, the lesion could be nicely dilated with a 3.0-mm balloon and a 3.0 × 33 mm drug-eluting stent was easily implanted at 14 bar and post-dilated with a 3.25-mm noncompliant balloon at 18 bar with excellent final angiographic and OCT results (Figures 1F and 3D to 3F).
Our findings demonstrate the value of coronary lithoplasty as a bail out procedure to tackle undilatable, severely calcified, de novo coronary lesions. This novel technique also seems to be of major help to optimize results of underexpanded stents presenting with in-stent restenosis in heavily calcified vessels.
All authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received November 14, 2018.
- Revision received December 9, 2018.
- Accepted December 13, 2018.
- 2019 American College of Cardiology Foundation