Treatment of Calcific Coronary Stenosis With Shockwave: A Case Report

Abstract Introduction Woman 72 years old, suffering from hypertensive ischemic heart disease, type II diabetes mellitus with accessory circulatory complications and pure hypercholesterolemia. He arrives at our cath lab urgently for ST–segment elevation myocardial infarction (STEMI). We proceed with coronary angiography to treat the culprit lesion. On the coronary angiographic picture, thrombotic occlusion is found at the proximal edge of the stent previously implanted in the middle right coronary artery, the left coronary artery shows mild diffuse atheromasia in the absence of angiographically significant stenosis. An attempt is made to reopen the vessel with multiple pre–dilations with semi–compliant and non–compliant balloon catheters without obtaining complete expansion. Given the impossibility of implanting the stent, dilation is performed with a 2.5x20mm medicated balloon for one minute and the use of Shockwave intravascular lithotripsy (IVL) is planned as a second step. Methods IVL involves the generation of pulsatile sound waves in the target site aimed at combating the occurrence of microfractures of the calcific tissue, modifying the compliance of the vessel, without however damaging it. In detail, the system is composed of an electrical pulse generator, a connection cable and a balloon catheter. After the standard preparation of the balloon with a mixture of saline solution/contrast medium, it is advanced on a 0.014" guide up to the level of the stenosis to be treated. Results After preparation and use of the shockwave intravascular lithotripsy (IVL) system with a 2.5x12 mm balloon, 5 cycles of 10 pulses were delivered for a total of 50 pulses. Dilation follows with a non–compliant 2.5x15 mm balloon with optimal expansion of the balloon. We then proceeded with the implantation of the 2.75x16 mm drug–eluting stent in the middle section overlapping with the stent already present. Obtaining a good final angiographic result and adequate coronary flow (TIMI 3). Conclusions The use of coronary intravascular lithotripsy made it possible to optimize the result of the previously failed angioplasty, pursuing an excellent angiographic result with limited risks, compared to other debulking systems.