Bailout Intravascular Lithotripsy for Calcium-Mediated Underexpansion of a Peripheral Covered Stent in an Emergency...

Severe iliofemoral calcification can compromise emergency endovascular control of access-site bleeding by preventing full covered-stent expansion at the landing zone. A 78-year-old man developed hemodynamic instability, right-flank pain, and severe anemia 6 h after ultrasound-guided right transfemoral primary percutaneous coronary intervention for anterior ST-segment elevation myocardial infarction. Contrast-enhanced computed tomography demonstrated a large right retroperitoneal hematoma with active extravasation from the distal external iliac artery, immediately proximal to a bulky calcified plaque involving the proximal common femoral artery (CFA). Through ultrasound-guided contralateral femoral access, an 8 mm × 60 mm self-expanding covered stent achieved immediate sealing of the external iliac artery injury but remained markedly underexpanded distally at the calcified CFA landing zone. Conventional 8-mm balloon post-dilation was attempted, but residual underexpansion persisted; further high-pressure dilation was avoided because of concern for rupture or perforation of the calcified iliofemoral segment and loss of the newly achieved seal. Bailout intravascular lithotripsy (IVL) with an 8 mm × 60 mm balloon consisted of 150 pulses delivered at 4 atm in repeated sequences, each followed by nominal-pressure post-dilation of the same balloon at 6 atm. Final angiography showed improved covered-stent expansion with approximately 30% residual stenosis and no recurrent extravasation, dissection, perforation, or distal embolization. The patient was discharged on postoperative day 8. At 12-month follow-up, duplex ultrasound confirmed covered-stent patency without edge stenosis, pseudoaneurysm, or hemodynamically significant restenosis. This case illustrates that IVL may provide a low-pressure bailout option for calcium-mediated peripheral covered-stent underexpansion during emergency vascular access-site repair; however, this off-label use requires careful device sizing, attention to covered-stent integrity, and structured imaging surveillance.