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Intracoronary lithotripsy for calcific neoatherosclerotic in-stent restenosis: a case report

Intracoronary lithotripsy for calcific neoatherosclerotic in-stent restenosis: a case report Downloaded from https://academic.oup.com/ehjcr/article/4/4/1/5855226 by DeepDyve user on 22 September 2020 CASE REPORT European Heart Journal - Case Reports (2020) 4, 1–4 doi:10.1093/ehjcr/ytaa117 Coronary heart disease Intracoronary lithotripsy for calcific neoatherosclerotic in-stent restenosis: a case report 1,2,3 1,2,3 1,2 Helena Tizo ´ n-Marcos , * Iris Rodrı ´guez-Costoya , Cristina Tevar , and 1,2,3 Beatriz Vaquerizo 1 2 Cardiology Department, Hospital del Mar, Passeig Marı´tim 25-29, 08003 Barcelona, Spain; Heart Diseases Biomedical Research Group, IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain; and Facultat de Medicina, Universitat Auto`noma de Barcelona, Bellaterra, Spain Received 21 October 2019; first decision 31 October 2019; accepted 7 April 2020; online publish-ahead-of-print 9 June 2020 Background In-stent restenosis is a difficult percutaneous scenario if calcific neoatherosclerosis is the underlying aetiology. ................................................................................................................................................................................................... Case summary A 69-year-old diabetic woman with a previous percutaneous coronary intervention on the left anterior descending coronary artery was readmitted for non-ST-elevation myocardial infarction. In-stent restenosis due to calcific neoa- therosclerosis was observed by intracoronary imaging during the intervention. Intravascular lithotripsy was used successfully to fracture the underlying calcific plaque. However, the balloon ruptured during treatment although this did not damage the artery. ................................................................................................................................................................................................... Discussion Intravascular lithotripsy is a promising tool for the treatment of extremely calcified lesions including calcific neoa- therosclerosis of in-stent restenosis. Balloon rupture is a complication of this new percutaneous treatment that has not previously been described. Keywords Restenosis Plaque modification Intracoronary lithotripsy Drug-eluting stent Case report • • • • Introduction Learning points . In-stent restenosis by underlying calcific neoatherosclerosis is a Coronary calcification is a strong predictor of major adverse cardiac challenging percutaneous scenario. . events after percutaneous coronary intervention (PCI) because it Rotational atherectomy may be performed with caution due complicates device delivery, expansion, and apposition, predisposing to risk of burr stuck if associated under-expansion of the stent 1 to stent failure. Intracoronary lithotripsy is a new tool for treatment is present. . of extremely calcified coronary lesions by fracturing the calcified pla- Intracoronary lithotripsy may be included into the tools to que, thus allowing mean area gain and facilitating stent apposition and treat extremely calcified lesions. 2,3 expansion. However, balloon rupture may occur during treatment. • . Intracoronary imaging should be performed to understand the . Prompt detection of this complication is needed so that rapid meas- aetiology of the in-stent restenosis and guide the treatment. ures can be taken to avoid damage to the vessel. * Corresponding author. Tel: þ34 93 2483489, Email: htizon@parcdesalutmar.cat Handling Editor: Panagiotis Xaplanteris Peer-reviewers: Julien Adjedj and Rafal Wolny Compliance Editor: Carlos Minguito Carazo Supplementary Material Editor: Peysh A. Patel V The Author(s) 2020. Published by Oxford University Press on behalf of the European Society of Cardiology. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com Downloaded from https://academic.oup.com/ehjcr/article/4/4/1/5855226 by DeepDyve user on 22 September 2020 2 H. Tizo´n-Marcos et al. non-compliant high-pressure balloon. Intravascular ultrasound Timeline (IVUS) showed there was neoatherosclerosis with a 360 calcific . arch at the proximal part of the LAD stent and at the proximal LAD; . there was no fracture on the calcific arch or dissection at the prox- . imal LAD (Supplementary material online, Video S2). The proximal 69-Year-old obese, diabetic, and asthmatic woman ................................................................................................. reference vessel size was 3.5 mm 3.6 mm (Figure 1B). 2003 Non-ST-elevation myocardial infarction (NSTEMI) Killip . Intravascular lithotripsy was planned in order to treat the calcified Class I: coronary angiography showed one vessel disease neoatherosclerosis and prevent sudden closure of the first diagonal treated with left anterior descending coronary artery . branch. Initially, lithotripsy with a 3.0 12 balloon at the mid-distal (LAD) stenting . part of the stent was performed. As a good expansion was achieved 2016 NSTEMI Killip Class I: coronary angiography showed non- . with two cycles of pulses, the balloon was then retrieved to the cen- significant in-stent restenosis and severe lesion at a mar- . tral and proximal part of the stent. However, the balloon ruptured at ginal branch of left circumflex treated with drug-eluting . the third cycle of pulses (Supplementary material online, Video S3), al- stent though it had been applied at the recommended pressure (4 atm). 2019 NSTEMI Killip Class III: coronary angiography showed dif- The emission of pulses was immediately stopped (Figure 1C) with dis- fuse in-stent LAD restenosis with positive haemodynam- tal downstream embolization of balloon contents. Transient ST- ic invasive testing. Intracoronary imaging with elevation on electrocardiogram and a drop in the blood pressure intravascular ultrasound revealed severe calcified neoa- . were observed and resolved with retrieval of the balloon and applica- therosclerosis. Plaque modification with intracoronary tion of intracoronary nitroprusside. A coronary angiography showed lithotripsy was performed. Balloon rupture occurred that there was no distal dissection or vessel rupture (Supplementary during treatment and distal embolization resolved with material online, Video S4). Then, another 3.5 12 lithotripsy balloon the retrieval of the balloon and intracoronary nitro- at proximal LAD was used to treat the proximal in-stent and prox- prussiate administration imal LAD (Figure 2A). Following lithotripsy, an IVUS showed multiple 2020 Uneventful at 12 months of follow-up fractures of the 360 calcific neoatherosclerosis plaque (Figure 2B, white arrows and Supplementary material online, Video S5). Then, a 3.5 mm 22 mm DES was implanted covering the proximal previous stent to the LAD ostium, expansion was good, and the final result Case presentation was excellent (Figure 2C and Supplementary material online, Video S6). The patient is on double antiplatelet therapy (with a recom- The patient was a 69-year-old woman, with diabetes mellitus, obesity, . mended duration of at least 12 months) and is still uneventful and asthma. In 2003, she had a non-ST-elevation myocardial infarc- . 12 months after the intervention. tion (NSTEMI) that was treated with a PCI at the proximal and mid-left anterior descending coronary artery (LAD) stent at another facility. In 2016, she was readmitted for a new NSTEMI. Coronary Discussion angiography showed a 45% in-stent restenosis and an 85% lesion at a marginal branch, which was treated with 2.75 mm 26 mm drug- . In-stent restenosis due to calcific neoatherosclerosis is a challenging eluting stent (DES). She did not attend post-hospitalization and was . scenario in which different PCIs such as rotational and orbital athe- lost to follow-up. In January 2019, she was again readmitted for . rectomy, intravascular lithotripsy, and intracoronary laser have been . 4–6 NSTEMI Killip Class III. . tested. The aim of all of these techniques is to adequately modify On physical examination, the patient was found to have hyperten- . the calcific plaque in order to obtain a sufficient minimal lumen area sion (non-invasive arterial pressure was 147/75 mmHg), tachycardia . and an expandable intima. Intravascular lithotripsy enables to treat (96 b.p.m.), a basal oxygen saturation of 94%, bilateral basal crackles, calcific lesions in arteries larger than 2.5 mm without dislodgement of debulked material, through a semi-compliant balloon. However, if no cardiac murmurs, and absence of limb oedema. Echocardiography the lesion is extremely severe or there is tortuosity at the proximal was not performed due to a poor acoustic window. Coronary angiography showed a moderate restenosis of the LAD part of the artery, the lithotripsy balloon may not advance into the le- stent with no other significant lesion (Figure 1A and Supplementary sion. In this case, a mother-in-child catheter may help to advance the material online, Video S1). During the diagnostic catheterization, inva- balloon into the lesion but if this technique is not successful, an alter- sive left ventricular (LV) end-diastolic pressure was measured reveal- native therapy (rotational atherectomy) may be used. ing high LV filling pressure (20 mmHg). An invasive haemodynamic So far, few complications had been reported from patients treated 2–9 evaluation with resting full-cycle ratio (RFR) was performed, finding a with this new technology. However, here we report the rupture significant LAD ischaemia (RFR 0.75) with a clear step-up into mid- of the balloon in the treatment of an in-stent restenosis lesion at the and proximal LAD. Two wires were inserted: one into the LAD and third cycle of pulses. Balloon laceration may be induced by fractured a second wire to protect the first diagonal branch. In contrast to . calcium from the atherosclerotic plaque, leading to balloon rupturing other plaque modification devices, intravascular lithotripsy may be . during the treatment. Intracoronary lithotripsy emitters stop as soon used safely with several wires left in place. Attempts to expand the . as there is no fluid inside the balloon; and then the propagation of the proximal part of the LAD stent and the proximal LAD were unsuc- pressure waves decreases and finally stops. Therefore, continuous cessful using a progressive 3.0 high-pressure cutting balloon and a 3.5 fluoroscopy is advisable for early detection of balloon leakage in Downloaded from https://academic.oup.com/ehjcr/article/4/4/1/5855226 by DeepDyve user on 22 September 2020 Intracoronary lithotripsy balloon rupture 3 Figure 1 Left coronary angiography (A) showing a diffuse in-stent restenosis involving proximal and mid-left anterior descending coronary artery. Initial treatment with a 3.0 mm cutting balloon and 3.5 mm non-compliant balloon that did not reach adequate expansion (B). Intravascular ultrasound performed after unsuccessful attempts to dilate left anterior descending coronary artery showed a 360 -calcific neoatherosclerosis involving the mid- and proximal part of the stent with a minimal diameter of 2 mm (C). Figure 2 Initial inflation of the lithotripsy balloon at the mid-stent left anterior descending coronary artery and rupture at 25 pulses with dye leak- age in distal left anterior descending coronary artery (A). Adequate expansion of the 3.5 mm 12 mm lithotripsy balloon at the proximal part of the left anterior descending coronary artery stent. Angiography and intravascular ultrasound performed after the lithoplasty showing calcium rupture and absence of vessel perforation or distal dissection (B). Final result after implantation of a 3.5 mm 22 mm drug-eluting stent (C). Downloaded from https://academic.oup.com/ehjcr/article/4/4/1/5855226 by DeepDyve user on 22 September 2020 4 H. Tizo´n-Marcos et al. order to rapidly stop the emission of pulses and protect the vessel Consent: The author/s confirm that written consent for submis- from further damage. sion and publication of this case report including image(s) and associated text has been obtained from the patient in line with . COPE guidance. Conclusion Conflict of interest: none declared. Intracoronary lithotripsy is a new technology that is becoming an es- sential tool to treat extremely calcified coronary lesions. However, References this procedure must still prove clinical benefits and safety in large ser- 1. Genereux P, Madhavan MV, Mintz GS, Maehara A, Palmerini T, Lasalle L, Xu K, ies with different types of calcific lesions. The larger series of studies McAndrew T, Kirtane A, Lansky AJ, Brener SJ, Mehran R, Stone GW. Ischemic are needed in order to confirm the good results of small series of outcomes after coronary intervention of calcified vessels in acute coronary syn- dromes. Pooled analysis from the HORIZONS-AMI (Harmonizing Outcomes cases and to assess the rate of complications, such as the balloon rup- . With Revascularization and Stents in Acute Myocardial Infarction) and ACUITY ture reported in this case study. (Acute Catheterization and Urgent Intervention Triage Strategy) TRIALS. JAm Coll Cardiol 2014;63:1845–1854. 2. Ali ZA, Brinton TJ, Hill JM, Maehara A, Matsumura M, Karimi Galougahi K, Illindala U, Go¨tber M, Whitbourn R, Van Mieghem N, Meredith IT, Di Mario C, Fajadet J. Lead author biography Optical coherence tomography characterization of coronary lithoplasty for treat- ment of calcified lesions: first description. JACC Cardiovasc Imaging 2017;10: Helena Tizo´n-Marcosisaninterven- 897–906. tional cardiologist interested in car- 3. Ali ZA, Nef H, Escaned J, Werner N, Banning AP, Hill JM, De Bruyne B, diac imaging. Montorfano M, Lefevre T, Stone GW, Crowley A, Matsumura M, Maehara A, . Lansky AJ, Fajadet J, Di Mario C. Safety and effectiveness of coronary intravascular lithotripsy for treatment of severely calcified coronary stenosis. Circ Cardiovasc Interv 2019;12:e008434. . 4. Chen G, Zrenner B, Pyxaras SA. Combined rotational atherectomy and intravas- cular lithotripsy for the treatment of severely calcified in-stent neoatherosclerosis: a mini-review. Cardiovasc Revasc Med 2019;20:819–821. 5. Ocaranza-Sa´nchez R, Abella´s-Sequeiros RA, Galv~ao-Braga C, Trillo-Nouche R, . Gonza´lez-Juanatey JR. Excimer laser coronary atherectomy during percutaneous coronary intervention. Rev Esp Cardiol (Engl Ed) 2016;69:867–868. 6. Salazar C, Escaned J, Tirado G, Gonzalo N. Recurrent restenosis caused by severe . calcific neoatherosclerosis treated with intravascular lithotripsy. EuroIntervention 2019; doi: 10.4244/EIJ-D-19-00268. [Epub ahead of print] 7. Rodrı´guez Costoya I, Tizo´n-Marcos H, Vaquerizo Montilla B, Salvatella Giralt N, . Martı´ Almor J, Milla´n Segovia R. Litoplastia coronaria: experiencia inicial en lesiones calcificadas. Rev Esp Cardiol 2019;72:788–790. Supplementary material 8. Wong B, El-Jack S, Newcombe R, Glenie T, Armstron G, Cicovic A, Khan A. . Shockwave intravascular lithotripsy of calcified coronary lesions in ST-elevation Supplementary material is available at European Heart Journal - Case myocardial infarction: first-in-man experience. J Invasive Cardiol 2019;31: Reports online. E73–E75. 9. Venuti G, D’Agosta G, Tamburino C, La Manna A. Coronary lithotripsy for failed Slide sets: A fully edited slide set detailing this case and suitable for . rotational atherectomy, cutting balloon, scoring balloon, and ultra-high-pressure local presentation is available online as Supplementary data. non-compliant balloon. Catheter Cardiovasc Interv 2019;94:E111–E115. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png European Heart Journal - Case Reports Oxford University Press

Intracoronary lithotripsy for calcific neoatherosclerotic in-stent restenosis: a case report

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© The Author(s) 2020. Published by Oxford University Press on behalf of the European Society of Cardiology.
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Abstract

Downloaded from https://academic.oup.com/ehjcr/article/4/4/1/5855226 by DeepDyve user on 22 September 2020 CASE REPORT European Heart Journal - Case Reports (2020) 4, 1–4 doi:10.1093/ehjcr/ytaa117 Coronary heart disease Intracoronary lithotripsy for calcific neoatherosclerotic in-stent restenosis: a case report 1,2,3 1,2,3 1,2 Helena Tizo ´ n-Marcos , * Iris Rodrı ´guez-Costoya , Cristina Tevar , and 1,2,3 Beatriz Vaquerizo 1 2 Cardiology Department, Hospital del Mar, Passeig Marı´tim 25-29, 08003 Barcelona, Spain; Heart Diseases Biomedical Research Group, IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain; and Facultat de Medicina, Universitat Auto`noma de Barcelona, Bellaterra, Spain Received 21 October 2019; first decision 31 October 2019; accepted 7 April 2020; online publish-ahead-of-print 9 June 2020 Background In-stent restenosis is a difficult percutaneous scenario if calcific neoatherosclerosis is the underlying aetiology. ................................................................................................................................................................................................... Case summary A 69-year-old diabetic woman with a previous percutaneous coronary intervention on the left anterior descending coronary artery was readmitted for non-ST-elevation myocardial infarction. In-stent restenosis due to calcific neoa- therosclerosis was observed by intracoronary imaging during the intervention. Intravascular lithotripsy was used successfully to fracture the underlying calcific plaque. However, the balloon ruptured during treatment although this did not damage the artery. ................................................................................................................................................................................................... Discussion Intravascular lithotripsy is a promising tool for the treatment of extremely calcified lesions including calcific neoa- therosclerosis of in-stent restenosis. Balloon rupture is a complication of this new percutaneous treatment that has not previously been described. Keywords Restenosis Plaque modification Intracoronary lithotripsy Drug-eluting stent Case report • • • • Introduction Learning points . In-stent restenosis by underlying calcific neoatherosclerosis is a Coronary calcification is a strong predictor of major adverse cardiac challenging percutaneous scenario. . events after percutaneous coronary intervention (PCI) because it Rotational atherectomy may be performed with caution due complicates device delivery, expansion, and apposition, predisposing to risk of burr stuck if associated under-expansion of the stent 1 to stent failure. Intracoronary lithotripsy is a new tool for treatment is present. . of extremely calcified coronary lesions by fracturing the calcified pla- Intracoronary lithotripsy may be included into the tools to que, thus allowing mean area gain and facilitating stent apposition and treat extremely calcified lesions. 2,3 expansion. However, balloon rupture may occur during treatment. • . Intracoronary imaging should be performed to understand the . Prompt detection of this complication is needed so that rapid meas- aetiology of the in-stent restenosis and guide the treatment. ures can be taken to avoid damage to the vessel. * Corresponding author. Tel: þ34 93 2483489, Email: htizon@parcdesalutmar.cat Handling Editor: Panagiotis Xaplanteris Peer-reviewers: Julien Adjedj and Rafal Wolny Compliance Editor: Carlos Minguito Carazo Supplementary Material Editor: Peysh A. Patel V The Author(s) 2020. Published by Oxford University Press on behalf of the European Society of Cardiology. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com Downloaded from https://academic.oup.com/ehjcr/article/4/4/1/5855226 by DeepDyve user on 22 September 2020 2 H. Tizo´n-Marcos et al. non-compliant high-pressure balloon. Intravascular ultrasound Timeline (IVUS) showed there was neoatherosclerosis with a 360 calcific . arch at the proximal part of the LAD stent and at the proximal LAD; . there was no fracture on the calcific arch or dissection at the prox- . imal LAD (Supplementary material online, Video S2). The proximal 69-Year-old obese, diabetic, and asthmatic woman ................................................................................................. reference vessel size was 3.5 mm 3.6 mm (Figure 1B). 2003 Non-ST-elevation myocardial infarction (NSTEMI) Killip . Intravascular lithotripsy was planned in order to treat the calcified Class I: coronary angiography showed one vessel disease neoatherosclerosis and prevent sudden closure of the first diagonal treated with left anterior descending coronary artery . branch. Initially, lithotripsy with a 3.0 12 balloon at the mid-distal (LAD) stenting . part of the stent was performed. As a good expansion was achieved 2016 NSTEMI Killip Class I: coronary angiography showed non- . with two cycles of pulses, the balloon was then retrieved to the cen- significant in-stent restenosis and severe lesion at a mar- . tral and proximal part of the stent. However, the balloon ruptured at ginal branch of left circumflex treated with drug-eluting . the third cycle of pulses (Supplementary material online, Video S3), al- stent though it had been applied at the recommended pressure (4 atm). 2019 NSTEMI Killip Class III: coronary angiography showed dif- The emission of pulses was immediately stopped (Figure 1C) with dis- fuse in-stent LAD restenosis with positive haemodynam- tal downstream embolization of balloon contents. Transient ST- ic invasive testing. Intracoronary imaging with elevation on electrocardiogram and a drop in the blood pressure intravascular ultrasound revealed severe calcified neoa- . were observed and resolved with retrieval of the balloon and applica- therosclerosis. Plaque modification with intracoronary tion of intracoronary nitroprusside. A coronary angiography showed lithotripsy was performed. Balloon rupture occurred that there was no distal dissection or vessel rupture (Supplementary during treatment and distal embolization resolved with material online, Video S4). Then, another 3.5 12 lithotripsy balloon the retrieval of the balloon and intracoronary nitro- at proximal LAD was used to treat the proximal in-stent and prox- prussiate administration imal LAD (Figure 2A). Following lithotripsy, an IVUS showed multiple 2020 Uneventful at 12 months of follow-up fractures of the 360 calcific neoatherosclerosis plaque (Figure 2B, white arrows and Supplementary material online, Video S5). Then, a 3.5 mm 22 mm DES was implanted covering the proximal previous stent to the LAD ostium, expansion was good, and the final result Case presentation was excellent (Figure 2C and Supplementary material online, Video S6). The patient is on double antiplatelet therapy (with a recom- The patient was a 69-year-old woman, with diabetes mellitus, obesity, . mended duration of at least 12 months) and is still uneventful and asthma. In 2003, she had a non-ST-elevation myocardial infarc- . 12 months after the intervention. tion (NSTEMI) that was treated with a PCI at the proximal and mid-left anterior descending coronary artery (LAD) stent at another facility. In 2016, she was readmitted for a new NSTEMI. Coronary Discussion angiography showed a 45% in-stent restenosis and an 85% lesion at a marginal branch, which was treated with 2.75 mm 26 mm drug- . In-stent restenosis due to calcific neoatherosclerosis is a challenging eluting stent (DES). She did not attend post-hospitalization and was . scenario in which different PCIs such as rotational and orbital athe- lost to follow-up. In January 2019, she was again readmitted for . rectomy, intravascular lithotripsy, and intracoronary laser have been . 4–6 NSTEMI Killip Class III. . tested. The aim of all of these techniques is to adequately modify On physical examination, the patient was found to have hyperten- . the calcific plaque in order to obtain a sufficient minimal lumen area sion (non-invasive arterial pressure was 147/75 mmHg), tachycardia . and an expandable intima. Intravascular lithotripsy enables to treat (96 b.p.m.), a basal oxygen saturation of 94%, bilateral basal crackles, calcific lesions in arteries larger than 2.5 mm without dislodgement of debulked material, through a semi-compliant balloon. However, if no cardiac murmurs, and absence of limb oedema. Echocardiography the lesion is extremely severe or there is tortuosity at the proximal was not performed due to a poor acoustic window. Coronary angiography showed a moderate restenosis of the LAD part of the artery, the lithotripsy balloon may not advance into the le- stent with no other significant lesion (Figure 1A and Supplementary sion. In this case, a mother-in-child catheter may help to advance the material online, Video S1). During the diagnostic catheterization, inva- balloon into the lesion but if this technique is not successful, an alter- sive left ventricular (LV) end-diastolic pressure was measured reveal- native therapy (rotational atherectomy) may be used. ing high LV filling pressure (20 mmHg). An invasive haemodynamic So far, few complications had been reported from patients treated 2–9 evaluation with resting full-cycle ratio (RFR) was performed, finding a with this new technology. However, here we report the rupture significant LAD ischaemia (RFR 0.75) with a clear step-up into mid- of the balloon in the treatment of an in-stent restenosis lesion at the and proximal LAD. Two wires were inserted: one into the LAD and third cycle of pulses. Balloon laceration may be induced by fractured a second wire to protect the first diagonal branch. In contrast to . calcium from the atherosclerotic plaque, leading to balloon rupturing other plaque modification devices, intravascular lithotripsy may be . during the treatment. Intracoronary lithotripsy emitters stop as soon used safely with several wires left in place. Attempts to expand the . as there is no fluid inside the balloon; and then the propagation of the proximal part of the LAD stent and the proximal LAD were unsuc- pressure waves decreases and finally stops. Therefore, continuous cessful using a progressive 3.0 high-pressure cutting balloon and a 3.5 fluoroscopy is advisable for early detection of balloon leakage in Downloaded from https://academic.oup.com/ehjcr/article/4/4/1/5855226 by DeepDyve user on 22 September 2020 Intracoronary lithotripsy balloon rupture 3 Figure 1 Left coronary angiography (A) showing a diffuse in-stent restenosis involving proximal and mid-left anterior descending coronary artery. Initial treatment with a 3.0 mm cutting balloon and 3.5 mm non-compliant balloon that did not reach adequate expansion (B). Intravascular ultrasound performed after unsuccessful attempts to dilate left anterior descending coronary artery showed a 360 -calcific neoatherosclerosis involving the mid- and proximal part of the stent with a minimal diameter of 2 mm (C). Figure 2 Initial inflation of the lithotripsy balloon at the mid-stent left anterior descending coronary artery and rupture at 25 pulses with dye leak- age in distal left anterior descending coronary artery (A). Adequate expansion of the 3.5 mm 12 mm lithotripsy balloon at the proximal part of the left anterior descending coronary artery stent. Angiography and intravascular ultrasound performed after the lithoplasty showing calcium rupture and absence of vessel perforation or distal dissection (B). Final result after implantation of a 3.5 mm 22 mm drug-eluting stent (C). Downloaded from https://academic.oup.com/ehjcr/article/4/4/1/5855226 by DeepDyve user on 22 September 2020 4 H. Tizo´n-Marcos et al. order to rapidly stop the emission of pulses and protect the vessel Consent: The author/s confirm that written consent for submis- from further damage. sion and publication of this case report including image(s) and associated text has been obtained from the patient in line with . COPE guidance. Conclusion Conflict of interest: none declared. Intracoronary lithotripsy is a new technology that is becoming an es- sential tool to treat extremely calcified coronary lesions. However, References this procedure must still prove clinical benefits and safety in large ser- 1. Genereux P, Madhavan MV, Mintz GS, Maehara A, Palmerini T, Lasalle L, Xu K, ies with different types of calcific lesions. The larger series of studies McAndrew T, Kirtane A, Lansky AJ, Brener SJ, Mehran R, Stone GW. Ischemic are needed in order to confirm the good results of small series of outcomes after coronary intervention of calcified vessels in acute coronary syn- dromes. Pooled analysis from the HORIZONS-AMI (Harmonizing Outcomes cases and to assess the rate of complications, such as the balloon rup- . With Revascularization and Stents in Acute Myocardial Infarction) and ACUITY ture reported in this case study. (Acute Catheterization and Urgent Intervention Triage Strategy) TRIALS. JAm Coll Cardiol 2014;63:1845–1854. 2. Ali ZA, Brinton TJ, Hill JM, Maehara A, Matsumura M, Karimi Galougahi K, Illindala U, Go¨tber M, Whitbourn R, Van Mieghem N, Meredith IT, Di Mario C, Fajadet J. Lead author biography Optical coherence tomography characterization of coronary lithoplasty for treat- ment of calcified lesions: first description. JACC Cardiovasc Imaging 2017;10: Helena Tizo´n-Marcosisaninterven- 897–906. tional cardiologist interested in car- 3. Ali ZA, Nef H, Escaned J, Werner N, Banning AP, Hill JM, De Bruyne B, diac imaging. Montorfano M, Lefevre T, Stone GW, Crowley A, Matsumura M, Maehara A, . Lansky AJ, Fajadet J, Di Mario C. Safety and effectiveness of coronary intravascular lithotripsy for treatment of severely calcified coronary stenosis. Circ Cardiovasc Interv 2019;12:e008434. . 4. Chen G, Zrenner B, Pyxaras SA. Combined rotational atherectomy and intravas- cular lithotripsy for the treatment of severely calcified in-stent neoatherosclerosis: a mini-review. Cardiovasc Revasc Med 2019;20:819–821. 5. Ocaranza-Sa´nchez R, Abella´s-Sequeiros RA, Galv~ao-Braga C, Trillo-Nouche R, . Gonza´lez-Juanatey JR. Excimer laser coronary atherectomy during percutaneous coronary intervention. Rev Esp Cardiol (Engl Ed) 2016;69:867–868. 6. Salazar C, Escaned J, Tirado G, Gonzalo N. Recurrent restenosis caused by severe . calcific neoatherosclerosis treated with intravascular lithotripsy. EuroIntervention 2019; doi: 10.4244/EIJ-D-19-00268. [Epub ahead of print] 7. Rodrı´guez Costoya I, Tizo´n-Marcos H, Vaquerizo Montilla B, Salvatella Giralt N, . Martı´ Almor J, Milla´n Segovia R. Litoplastia coronaria: experiencia inicial en lesiones calcificadas. Rev Esp Cardiol 2019;72:788–790. Supplementary material 8. Wong B, El-Jack S, Newcombe R, Glenie T, Armstron G, Cicovic A, Khan A. . Shockwave intravascular lithotripsy of calcified coronary lesions in ST-elevation Supplementary material is available at European Heart Journal - Case myocardial infarction: first-in-man experience. J Invasive Cardiol 2019;31: Reports online. E73–E75. 9. Venuti G, D’Agosta G, Tamburino C, La Manna A. Coronary lithotripsy for failed Slide sets: A fully edited slide set detailing this case and suitable for . rotational atherectomy, cutting balloon, scoring balloon, and ultra-high-pressure local presentation is available online as Supplementary data. non-compliant balloon. Catheter Cardiovasc Interv 2019;94:E111–E115.

Journal

European Heart Journal - Case ReportsOxford University Press

Published: Aug 1, 2020

There are no references for this article.