Breaking The Stone: Stentless Coronary Revascularization with Intravascular Lithotripsy and Drug-Coated Balloon...

Background: Severe coronary calcification remains a major challenge in percutaneous coronary intervention (PCI), often complicating lesion preparation and stent expansion. Intravascular lithotripsy (IVL) enables controlled plaque modification through acoustic pressure waves, while drug-coated balloons (DCB) offer antiproliferative therapy without leaving a permanent scaffold. Case summary: We report two cases of severe calcified coronary stenosis treated with calcium modification techniques, intravascular lithotripsy, and drug-coated balloon technology. The first 73-year-old patient presented with a non-ST-elevation myocardial infarction. Coronary angiography identified a heavily calcified mid-LAD lesion. Optical coherence tomography revealed severe concentric calcification with a circumferential arc exceeding 270°, thickness 0.76 mm, length 12 mm, MLA 1.9 mm², prompting the use of intravascular lithotripsy (IVL) for lesion modification. The therapy achieved multiple calcium fractures and optimal luminal gain. As final therapeutic modality, drug-coated balloon angioplasty (DCB) was chosen, after which TIMI 3 flow was maintained with no dissection. In the second case, a 53-year-old male patient presented with cardiogenic shock and multivessel coronary artery disease. After the initial life-saving procedure, a second intervention on a heavily calcified 360° arc on the proximal LAD was performed under guidance with intravascular ultrasound (IVUS) with a cutting balloon and IVL, achieving excellent luminal gain, and DCB was used as a final treatment device. At follow-up, the patients remained asymptomatic, underscoring the safety and efficacy of a stent-less IVL + DCB strategy in complex calcified anatomy. Discussion: IVL's excellent safety profile and uniform circumferential action make it especially suitable for thick, concentric calcification. Likewise, contemporary DCB studies in de novo lesions have shown comparable mid-term results to DES in selected patients, supporting a "leave-nothing-behind" philosophy when optimal lesion preparation and imaging guidance are achieved. Take-home message: In appropriately selected patients, IVL-assisted plaque modification followed by DCB can achieve optimal outcomes while avoiding permanent implants and their late complications.