ELCA-Tripsy: Combination of Laser and Lithotripsy for Severely Calcified Lesions

J INVASIVE CARDIOL 2021;33(9):E754-E755.

Key words: excimer-laser coronary angioplasty, intravascular lithotripsy

A 61-year-old patient presented an acute occlusion of the mid-right coronary artery (RCA) (Figure 1A). After predilation at the mid RCA, a distal calcified stenosis was observed (Figure 1B). As several attempts to deliver balloons to the distal vessel were unsuccessful, 2 overlapping drug-eluting stents were implanted at the mid RCA. Subsequently, the distal lesion (Figure 1C) was predilated with 1.0, 1.5, 2.0, and 2.5 mm non-compliant balloons with severe underexpansion (Figure 1D). In a second procedure, a 2.5 x 12 mm Shockwave balloon (Shockwave Medical) could not cross the lesion (Figure 1E). A 0.9 mm Excimer laser coronary angioplasty (ELCA) catheter (80 mJ/mm², 80 Hz) crossed the lesion (Figure 1F) and permitted subsequent delivery of the Shockwave balloon. After 80 pulses, it achieved good expansion (Figure 1G). Subsequently, another drug-eluting stent was implanted (Figure 1H). Optical coherence tomography  demonstrated deep calcified plaques with fractures produced by intravascular lithotripsy (IVL) and good final result (Figure 2).

Rotational atherectomy (RA) and IVL are complementary calcium-debulking techniques. RA ablates intimal calcium and makes a channel that permits crossing of the Shockwave balloon, which  cannot be easily delivered through severe lesions. Shockwave completes lesion preparation, cracking deep calcium. When RA is discouraged, ELCA in combination with IVL (ELCA-Tripsy) may be useful, as ELCA facilitates Shockwave balloon delivery without impairment of recently implanted stents. To the best of our knowledge, this is the first description of this technique.