IVUS-Guided Orbital Atherectomy and Intravascular Lithotripsy for Severely Calcified Coronary Lesions

Severely calcified coronary lesions complicate percutaneous coronary intervention (PCI) by impairing device delivery and stent expansion, often necessitating advanced plaque-modification strategies.

Three patients with calcified left anterior descending artery disease underwent intravascular ultrasound (IVUS)-guided PCI with orbital atherectomy (OA), intravascular lithotripsy (IVL), and balloon dilation. In patient 1, a balloon-uncrossable lesion was treated with OA, followed by IVL when balloon dog-boning suggested residual deep calcium. In patient 2, OA-related dissection and slow flow were managed with provisional stenting, followed by IVL for persistent proximal calcium-related resistance. In patient 3, Ellis type III coronary perforation during postatherectomy balloon dilation was sealed with a covered stent, followed by IVL for proximal lesion preparation. Angiographic and IVUS assessments showed stent expansion and apposition in patients, with no adverse events during the 5-month follow-up.

These cases illustrate the feasibility of an IVUS-guided escalation strategy for resistant calcified coronary lesions.

This case series suggests that a stepwise, IVUS-guided multimodality strategy may facilitate successful outcomes and aid optimal stent deployment in complex calcified PCI.