Cracking the Plaque With Coronary Lithotripsy: Mechanistic Insights From Optical Coherence Tomography

J INVASIVE CARDIOL 2020;32(1):E14.

Key words: coronary lithoplasty, optical coherence tomography, undilatable lesion

A 38-year-old male underwent successful recanalization of a chronic total occlusion (CTO) in a bare-metal stented segment of the mid right coronary artery (RCA) via retrograde approach. However, the in-stent restenotic lesion was undilatable despite pressure up to 35 atm with non-compliant (NC) OPN balloons (SIS Medical AG). The patient was discharged with plans for a future attempt. Six months later, coronary angiography revealed patency of the RCA with residual severe in-stent restenosis. Predilation with a 2.5 x 15 mm OPN NC balloon up to 35 atm confirmed the undilatable restenotic lesion with dog-boning effect. Therefore, coronary lithoplasty with the Coronary Rx Intravascular Lithotripsy System (Shockwave Medical) was performed with a 2.5 x 12 mm balloon, delivering 8 series of lithotripsy. Subsequent dilation with a 3.0 x 15 mm OPN NC balloon at 35 atm was sufficiently effective and 5 overlapping drug-eluting stents were successfully deployed from the posterior-lateral ramus to ostial RCA. Coronary angiography and optical coherence tomography with the Ilumien Therapy Guidance System (St. Jude Medical) findings are shown in Figure 1.

Coronary lithoplasty is a promising technique that can overcome issues regarding the treatment of undilatable, heavily calcified, de novo and in-stent restenotic lesions, allowing plaque modification and successful stent deployment as demonstrated by intravascular imaging.

From the Division of Cardiology, Policlinico Hospital, University of Catania, Catania, Italy.

Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. The authors report no conflicts of interest regarding the content herein.

The authors report that patient consent was provided for publication of the images used herein.

Manuscript accepted March 15, 2019.

Address for correspondence: Dr Alessio La Manna, Division of Cardiology – CAST, Policlinico Hospital, via S. Sofia 78, 95123 Catania, Italy. Email: lamanna.cardio@gmail.com