From Ulnar Access to Intravascular Lithotripsy in the Emergency Setting: A Unique Case of Acute ST-Elevation Myocardial Infarction Recapitulating Several Niche Interventional Cardiology Techniques for Primary Percutaneous Coronary Intervention

Primary percutaneous coronary intervention (PCI) for ST-elevation myocardial infarction (STEMI) typically relies on well-established access and device strategies. However, complex anatomical constraints may necessitate unconventional approaches. We report a case of acute anterior STEMI in a dialysis-dependent patient with no usable radial or femoral access. Ulnar artery cannulation enabled emergency angiography, revealing a long, calcified proximal left anterior descending artery occlusion. A microcatheter-specialty guidewire combination achieved lesion crossing, followed by guide extension catheter support to facilitate delivery. Intravascular lithotripsy (IVL) was employed to modify extensive calcification, allowing for stent implantation with restoration of TIMI 3 flow. The patient had an uneventful recovery. This case underscores the procedural relevance of niche interventional techniques—including alternative access, advanced lesion crossing strategies, guide support augmentation, and IVL—in select, high-risk STEMI patients. The discussion contextualizes each tool within the evidence base, suggesting that such a sequential, integrative strategy may be valuable when standard PCI is inadequate. As the prevalence of severe coronary calcification rises, especially among patients with chronic kidney disease or peripheral artery disease, awareness and appropriate deployment of these adjuncts may expand the boundaries of effective emergent PCI.