An Unusual Shockwave Complication: A Case of Type III Coronary Artery Perforation Following Intravascular Lithotripsy in a Severely Calcified Coronary Lesion

Shockwave intravascular lithotripsy (S-IVL) has been increasingly adopted for the treatment of severely calcified coronary lesions, offering an innovative and controlled method of calcium modification. While the technique is generally safe, coronary artery perforation (CAP) remains a rare but life-threatening complication. We report the case of a 71-year-old man with an extensive, long, calcified stenosis of the proximal-mid left anterior descending (LAD) artery, who underwent elective percutaneous coronary intervention (PCI) with S-IVL followed by high-pressure inflation using a non-compliant balloon. Immediately after post-dilatation, he developed an Ellis Type III LAD perforation with pericardial effusion and hemodynamic collapse. Urgent pericardiocentesis and implantation of a covered stent achieved complete sealing and restored coronary flow. The patient stabilized rapidly, was discharged without sequelae, and a follow-up optical coherence tomography (OCT) confirmed optimal stent apposition and vessel integrity. This case adds to the limited published reports of S-IVL-associated perforation, highlighting the interplay between acoustic plaque fracture and subsequent mechanical dilation in complex calcified anatomy, and emphasizing the importance of intravascular imaging and readiness for immediate complication management.