Navigating the Hardest Knots: Multimodality Plaque Modification for a Severely Calcified Ostial Circumflex Lesion in a Renal Transplant Recipient: A Case Report

Case DesCriptionA 68-year-old man presented with unstable angina and marked ECG changes.His cardiovascular risk factors included longstanding type 2 diabetes mellitus and hypertension.He had undergone renal transplantation (2012), PCI to the LAD (2014) and to the RCA (2018). introDuCtionCoronary artery calcification is increasingly encountered during contemporary percutaneous coronary intervention (PCI), particularly among elderly patients, diabetics, and those with chronic kidney disease.Severe calcification impairs balloon expansion, limits stent delivery, predisposes to stent underexpansion, and is associated with higher rates of restenosis, target lesion failure, and major adverse cardiovascular events.1,2 Lesions involving the left main (LM) bifurcation are especially challenging because inadequate lesion preparation and incomplete stent expansion may compromise large areas of myocardium and adversely affect long-term outcomes.Intravascular imaging has become central to the management of these lesions by accurately defining vessel dimensions, calcium morphology, and procedural endpoints.3 Intravascular lithotripsy is a novel calcium-modification technology that generates localized acoustic pressure waves capable of fracturing both superficial and deep calcium while minimizing vascular injury.[4][5][6][7] Compared with atherectomy-based strategies, intravascular lithotripsy (IVL) is associated with a favorable safety profile.We report a successful intravascular ultrasound (IVUS)-guided IVL-assisted PCI for a severely calcified distal left main-osteoproximal circumflex bifurcation lesion in a renal transplant recipient.