IVUS-Guided Orbital Atherectomy and Intravascular Lithotripsy for Severely Calcified Coronary Lesions

Q: What is the clinical evidence from this study?

Study design: Case Report. Population: Severely calcified coronary lesions (n=3). Intervention: IVUS-guided orbital atherectomy and intravascular lithotripsy. Primary outcome: Stent expansion, apposition, and adverse events (death, MI, TLR, recurrent angina) at 5-month follow-up.

Q: What does this research mean for the field?

A stepwise, IVUS-guided escalation strategy combining orbital atherectomy and intravascular lithotripsy is feasible and facilitates optimal stent deployment in complex, severely calcified coronary lesions. Novelty: ClaimNovelty.CONFIRMATORY. Consensus alignment: ConsensusAlignment.NEUTRAL.

Saroj Kumar Sahoo; Rajesh Vijayvergiya; Ramachandra Barik; Vikas Kadiyala; Anindya Banerjee; Debasis Panda; Prabhat Kumar Singh; Md Rubel Hossian; Melvin Baby; Mohan Kumar

doi:10.1016/j.jaccas.2026.109572

August 3, 2026JACC Case ReportsOpen Access

IVUS-Guided Orbital Atherectomy and Intravascular Lithotripsy for Severely Calcified Coronary Lesions

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Key result

IVUS-guided orbital atherectomy plus lithotripsy achieves successful stent expansion in severe calcification with zero 5-month events.

n=3

Why the study?

Severely calcified coronary lesions complicate PCI by impairing device delivery and stent expansion, often requiring advanced plaque-modification strategies with unclear optimal sequencing and imaging thresholds.

Key Points

To evaluate the feasibility and procedural outcomes of an intravascular ultrasound (IVUS)-guided escalation strategy combining orbital atherectomy (OA) and intravascular lithotripsy (IVL) for severely calcified coronary lesions.
Case series of 3 patients with severely calcified left anterior descending artery disease undergoing IVUS-guided percutaneous coronary intervention.
Patients received sequential plaque modification using a 1.25 mm crown OA device followed by IVL (80 pulses delivered at 3.0 mm or 3.5 mm) based on balloon behavior and IVUS findings.
Outcomes included procedural success, management of complications, and clinical adverse events assessed at 5 months of follow-up.
All 3 patients achieved successful lesion preparation and drug-eluting stent deployment, yielding final minimum stent areas ranging from 4.5 mm² to 11.9 mm² across treated segments.
Procedural complications included distal dissection with slow flow in patient 2 treated with provisional stenting, and an Ellis type III perforation in patient 3 sealed with a 2.8 × 19 mm covered stent prior to completing IVL.
At 5 months of clinical follow-up, no adverse events were reported across all 3 patients.

Study Design

Type

Case Report (n=3)

Multicenter

No

Structured PICO

P

Population

3 patients with severely calcified left anterior descending artery disease managed with an IVUS-guided multimodality percutaneous coronary intervention, followed for 5 months.

I

Intervention

IVUS-guided plaque modification strategy utilizing orbital atherectomy (OA) followed by adjunctive intravascular lithotripsy (IVL) and balloon dilation prior to drug-eluting stent implantation.

O

Outcome

Stent expansion and apposition on angiographic and IVUS assessments, and occurrence of adverse events at 5-month follow-up.

A stepwise, IVUS-guided multimodality strategy utilizing orbital atherectomy followed by intravascular lithotripsy may facilitate successful lesion preparation and optimal stent deployment in complex severely calcified coronary lesions.

Limitations

Describes only 3 patients from a single center, limiting generalizability
All lesions involved the LAD, and observations may not apply to other coronary territories
Nonconsecutive nature of the series introduces potential selection and reporting bias
Follow-up was limited to 5 months and does not permit assessment of long-term outcomes
Imaging findings that prompted escalation reflect operator judgment rather than prospectively validated thresholds
Only 3 patients from a single center, limiting generalizability.
All lesions involved the LAD, and observations may not apply to other coronary territories.
Nonconsecutive nature of the series introduces potential selection and reporting bias.
Follow-up was limited to 5 months and does not permit assessment of long-term outcomes.
Imaging findings that prompted escalation from OA to IVL reflect operator judgment rather than prospectively validated thresholds.

Implication

Hypothesis-generating in 3 cases; leaves open whether combined OA-IVL improves outcomes in severely calcified lesions.

Abstract

BACKGROUND: Severely calcified coronary lesions complicate percutaneous coronary intervention (PCI) by impairing device delivery and stent expansion, often necessitating advanced plaque-modification strategies. CASE SERIES: Three patients with calcified left anterior descending artery disease underwent intravascular ultrasound (IVUS)-guided PCI with orbital atherectomy (OA), intravascular lithotripsy (IVL), and balloon dilation. In patient 1, a balloon-uncrossable lesion was treated with OA, followed by IVL when balloon dog-boning suggested residual deep calcium. In patient 2, OA-related dissection and slow flow were managed with provisional stenting, followed by IVL for persistent proximal calcium-related resistance. In patient 3, Ellis type III coronary perforation during postatherectomy balloon dilation was sealed with a covered stent, followed by IVL for proximal lesion preparation. Angiographic and IVUS assessments showed stent expansion and apposition in patients, with no adverse events during the 5-month follow-up. DISCUSSION: These cases illustrate the feasibility of an IVUS-guided escalation strategy for resistant calcified coronary lesions. TAKE-HOME MESSAGE: This case series suggests that a stepwise, IVUS-guided multimodality strategy may facilitate successful outcomes and aid optimal stent deployment in complex calcified PCI.

Discussion

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Cite This Study

Sahoo et al. (2026) conducted a case report in Severely calcified coronary lesions (n=3). IVUS-guided orbital atherectomy and intravascular lithotripsy was evaluated on Stent expansion, apposition, and adverse events (death, MI, TLR, recurrent angina) at 5-month follow-up.

synapsesocial.com/papers/6ad0fc7415427f6a84040163 https://doi.org/10.1016/j.jaccas.2026.109572

Topics

Coronary artery disease

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IVUS-Guided Orbital Atherectomy and Intravascular Lithotripsy for Severely Calcified Coronary Lesions

Key Points

Study Design

Structured PICO

Limitations

Implication

Abstract

Discussion

Cite This Study

Topics

IVUS-Guided Orbital Atherectomy and Intravascular Lithotripsy for Severely Calcified Coronary Lesions

Key Points

Study Design

Structured PICO

Limitations

Implication

Abstract

Discussion

Cite This Study

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Topics

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