Undefeatable coronary lesion.

Area of Science:

• Interventional Cardiology
• Cardiovascular Imaging
• Vascular Biology

Background:

• Percutaneous coronary intervention (PCI) is a cornerstone treatment for coronary artery disease.
• Accurate lesion assessment is crucial for successful stent deployment and optimal long-term outcomes.
• Underexpansion of coronary stents remains a significant predictor of adverse events, including stent thrombosis and restenosis.

Observation:

• A case is presented where a mid-left anterior descending (LAD) artery calcification was initially not apparent on coronary angiography.
• Inappropriate predilation was performed, followed by stent implantation.
• The implanted stent demonstrated significant underexpansion, suggesting a challenging lesion morphology.

Findings:

• Despite multiple attempts including high-pressure balloon inflation, buddy wire technique, scoring, and cutting balloon angioplasty, full stent expansion could not be achieved.
• The underexpanded stent in the calcified LAD lesion indicates a technical challenge during PCI.
• The initial angiogram failed to reveal the extent of calcification, leading to suboptimal predilation and subsequent stent issues.

Implications:

• This case underscores the importance of meticulous pre-procedural assessment and recognition of calcified lesions, even when subtle on initial angiography.
• Advanced imaging modalities may be beneficial in cases with suspected significant calcification.
• Failure to achieve adequate stent expansion in complex lesions necessitates consideration of alternative strategies or adjunctive therapies to improve procedural success and patient outcomes.