True lumen stenting guided by IVUS-confirmed wire repositioning from the subintimal space following balloon inflation during IVL-induced coronary dissection: a case report

Figure 1. (A and B) Angiography images showing severe disease in the proximal to mid-left anterior descending artery, with marked tortuosity and heavy calcification. Arrows indicate anatomical locations within the proximal left anterior descending artery corresponding to intravascular ultrasound images. (C) Eccentric wire bias adjacent to calcified plaque (arrow). (D) Eccentric calcified lesion (arrow). (E) Soft plaque within a tight lesion (arrow). (F) Concentric calcified lesion (arrow).

Figure 2. (A) Angiographic image following intravascular lithotripsy performed in the proximal to mid-left anterior descending artery (dashed line), showing a Type C coronary artery dissection in the proximal left anterior descending segment. Arrows indicate anatomical locations corresponding to intravascular ultrasound images. Arrows also denote the true lumen. (B) Intravascular ultrasound image showing medial disruption and migration of both the wire and intravascular ultrasound catheter into the subintimal space. (C) Intravascular ultrasound image demonstrating the wire and catheter located behind the calcified plaque, within the subintimal space. (D) Intravascular ultrasound image confirming the wire’s position in the subintimal space adjacent to the true lumen.

Figure 3. (A) A 3.5 × 16 mm drug-eluting stent implanted in the mid-left anterior descending artery. (B) Real-time intravascular ultrasound evaluation of the behaviour and dynamics of a semi-compliant 2.0 mm balloon. (C) A 4.0 × 18 mm drug-eluting stent intentionally deployed in the true lumen over a wire that had migrated into the subintimal space.

Figure 4. (A–C) Intravascular ultrasound images obtained sequentially from proximal to distal segments within the proximal left anterior descending, showing migration of both the intravascular ultrasound catheter and an additional wire into the subintimal space. (D–F) Corresponding intravascular ultrasound images following balloon inflation demonstrating repositioning of a semi-compliant 2.0 mm balloon and an additional wire from the subintimal space into the true lumen. The arrows indicate the additional wire.

Figure 5. (A) Final coronary angiography following stent implantation. (B–D) Intravascular ultrasound images obtained sequentially from the proximal to distal segments within the proximal left anterior descending, confirming drug-eluting stent deployment in the true lumen at the site where the wire had migrated into the subintimal space. Post-dilatation resulted in good symmetric stent expansion and acceptable lumen gain.