Background: Balloon dilation and atherectomy have several limitations in the treatment
of heavily calcific coronary lesions.
Introduction: Intravascular lithotripsy (IVL) is a state-of-the-art system that modifies severe calcific
coronary plaques efficiently. In this paper, we report our experience with IVL in the context of a
calcific in-stent chronic total occlusion.
Case Summary: A 75-year-old gentleman whose status was post percutaneous coronary intervention,
with the deployment of two overlapping bare-metal stents in the mid-left anterior descending
artery (LAD) 20 years ago, was admitted to our cardiac center for the elective intervention of in-stent
chronic total occlusion (CTO) of LAD, which was performed using an antegrade wire escalation
(AWE) technique. After recanalization of the CTO body, optical coherence tomography pullback
confirmed a very high calcium score. Balloon dilatation attempts failed, so we proceeded with
shockwave lithotripsy with successful full expansion of the 3.5-mm IVL balloon followed by a
straightforward stent delivery. The procedure was complicated by distal wire perforation, which
was handled in a timely manner with coil embolization. The patient’s postoperative course was uneventful.
Conclusion: This case illustrates the feasibility and effectiveness of IVL that powerfully cracks
coronary calcium while minimizing vessel wall trauma in the context of heavily calcific in-stent
CTO. In our case, coronary perforation occurred in a small-caliber side branch, which was identified
in a timely manner before hemodynamic compromise and treated successfully straight away
with coil embolization.