Buddy Wire-Augmented Intravascular Lithotripsy in Refractory Calcified Coronary Lesions: A Five-Case Series

Heavily calcified coronary lesions remain a major challenge in percutaneous coronary intervention (PCI), often limiting the effectiveness of intravascular lithotripsy (IVL). We report a five-case series in which IVL failed to achieve adequate lesion modification but was successfully augmented by the addition of one or more buddy wires. Lesion subsets included severe proximal right coronary artery calcification, IVL balloon rupture with preserved efficacy, nodular calcification refractory to atherectomy, stent underexpansion causing recurrent ST-segment elevation myocardial infarction, and a concentric lesion assessed with optical coherence tomography (OCT). In the OCT-guided case, buddy wire-augmented IVL produced multiple additional calcium fracture lines and significant luminal gain without further balloon dilation. These findings support a hypothesis-generating mechanism of mechanical-acoustic coupling, whereby guidewires may facilitate localized amplification of shockwave energy. Buddy wire-augmented IVL may represent a simple and effective adjunctive strategy in resistant calcified lesions.