Overcoming very late severe calcific stenosis due to two layers of under-expanded stents with intravascular lithotripsy treatment: A case report

A case of covered stent failure in sealing up a coronary perforation potentially related to intravascular lithotripsy treatment: insights from optical coherence tomography

BACKGROUND

Intravascular lithotripsy (IVL) is a new modality in treatment of calcified coronary lesions which improves procedural outcomes. Coronary perforation is an extremely uncommon but potentially catastrophic complication of percutaneous coronary intervention (PCI) and IVL therapy.

CASE SUMMARY

We report a case of an elective PCI to a calcified left anterior descending (LAD) and diagonal bifurcation lesion in a 65-year-old man. LAD was treated with two stents. Despite high pressure non-compliant balloon inflation, a focal area of under-expansion remained. IVL successfully treated the under-expansion but was complicated with a large coronary perforation. The perforation was successfully sealed with a PK-PAPYRUS covered stent sacrificing the diagonal branch. Patient remained stable until 3 hours later when he developed tamponade requiring urgent pericardial drainage. Repeat angiography demonstrated recanalization of the diagonal branch and ongoing contrast extravasation along its course. Optical coherence tomography intracoronary imaging was used to delineate the mechanism of ongoing bleeding. This demonstrated an interrupted elastic membrane of the covered stent, potentially caused by underlying fractured calcium. Therefore, a second overlying PAPYRUS stent was deployed which satisfactorily sealed the perforation.

DISCUSSION

IVL is an emerging less invasive treatment for calcified coronary stenosis but could be associated with drastic complications. This case highlights the importance of awareness of IVL-related coronary perforation and the potential limitation of new generation thinner-wall covered stents. Intracoronary imaging plays an important role in identifying mechanisms of stent failure, tailoring treatment, and optimizing outcomes.

Contemporary Evidence-Based Diagnosis and Management of Severe Coronary Artery Calcification

Percutaneous treatment of heavily calcified coronary lesions remains a challenge for interventional cardiologists with increased risk of incomplete lesion preparation, suboptimal stent deployment, procedural complications, and a higher rate of acute and late stent failure. Adequate lesion preparation through calcium modification is crucial in optimising procedural outcomes. Several calcium modification devices and techniques exist, with rotational atherectomy the predominant treatment for severely calcified lesions. Novel technologies such as intravascular lithotripsy are now available and show promise as a less technical and highly effective approach for calcium modification. Emerging evidence also emphasises the value of detailed characterisation of calcification severity and distribution especially with intracoronary imaging for appropriate device selection and individualised treatment strategy. This review aims to provide an overview of the non-invasive and invasive evaluation of coronary calcification, discuss calcium modification techniques and propose an algorithm for the management of calcified coronary lesions.