Standardized Protocol for Intravascular Ultrasound-Guided Lithotripsy in Severely Calcified Coronary Lesions

Severe coronary artery calcification poses a clinical challenge during percutaneous coronary intervention, significantly increasing the risk of stent underexpansion and subsequent adverse cardiovascular events. While intravascular lithotripsy (IVL) uses acoustic pressure waves to modify calcified plaques, its use without precise intracoronary imaging can lead to suboptimal balloon sizing and unpredictable anatomical outcomes. The primary goal of the presented protocol is to detail a standardized, step-by-step methodology for utilizing intravascular ultrasound (IVUS) to guide IVL therapy in patients with heavily calcified coronary lesions. The protocol delineates strict criteria for baseline IVUS evaluation to accurately identify calcium arcs greater than 180° and determine the exact reference vessel diameter, thereby enabling a precise 1:1 IVL balloon-to-artery sizing ratio. Subsequent steps detail the targeted delivery of acoustic pulses at working pressures of 4-6 atm, followed by mandatory post-intervention IVUS pullbacks to visually confirm the induction of multiplanar calcium fractures and ensure optimal final stent apposition. Application of this standardized workflow in a real-world, highly comorbid cohort of 44 patients resulted in a 100% procedural success rate. Quantitative imaging confirmed a statistically significant expansion of the minimum lumen area (MLA) from a baseline of 1.25 mm² ± 0.25 mm² to a final post-stent area of 8.56 mm² ± 0.42 mm², alongside the reduction in severity grade of concentric calcifications. Furthermore, the protocol demonstrated a favorable periprocedural safety profile, with no severe device-related complications, as evidenced by stable cardiac biomarker trajectories and a 0% incidence of major adverse cardiovascular events (MACE) over an extended clinical follow-up period of 6-18 months. Ultimately, adherence to this IVUS-guided IVL protocol provides a reproducible, systematic framework to optimize lesion preparation and facilitate robust stent deployment in complex cardiovascular interventions.