Safety and procedural outcomes of intravascular lithotripsy in calcified coronaries in Indian patients

Abstract

Objective: Calcified coronaries still remain a major challenge for interventional cardiologist. This study aims to evaluate safety and efficacy of intravascular lithotripsy (IVL) in management of coronary artery calcification.

Methods: This was a retrospective single centre study regarding the utility of IVL in management of calcified coronaries. Patients with hemodynamically stable acute coronary syndrome or symptomatic chronic coronary syndrome (CCS) and calcified coronaries on angiography and who underwent IVL were enrolled. Intravascular imaging was performed wherever feasible. The primary endpoint was procedural success. In addition, data regarding procedural complications were collected.

Results: A total of 29 patients underwent IVL with a majority being males and having comorbidities such as hypertension and diabetes. A procedural success rate of 93.1% was achieved with no patient having >50% residual stenosis. IVL catheter was successfully delivered in all patients. The mean catheter diameter was 3.3 ± 0.4 mm and mean number of delivered pulses was 70.3 ± 16.4. The arteries most commonly intervened were the left main coronary and the left anterior descending artery. Intracoronary imaging revealed a significant increase in minimum luminal cross-sectional area (MLA) post IVL (pre-MLA: 5.1 ± 2.5 mm²; post-MLA: 10.7 ± 2.9 mm²; P<0.001). Two patients had in-hospital MACE in form of peri-procedural non Q-wave MI. No patient had arrhythmias, stent thrombosis, coronary perforation, or slow flow/no-reflow. Two patients had a rupture of IVL balloon while four had coronary artery dissection.

Conclusions: IVL is a safe and highly effective modality with high procedural success rate in management of calcified coronaries.

Keywords: Angiogram; Calcification; Imaging; Lithotripsy; Stent.

Fig. A.1

A: Coronary angiogram left anterior oblique (LAO) cranial view showing diffuse disease in proximal and mid left anterior descending (LAD) artery with concentric calcification. B: Coronary angiogram LAO cranial view post drug eluting stent (DES) implantation in proximal and mid LAD following IVL with less than 50% residual stenosis and a Thrombolysis in Myocardial Infarction (TIMI) III flow. C: Optical coherence tomography (OCT) image pre-intravascular lithotripsy (IVL) showing concentric calcification [asterisk (∗)] with a minimum lumen area (MLA) of 2.99 mm² while post IVL OCT image shows multiple calcium fractures [asterisk (∗)] with significant increase in MLA to 5.67 mm².

Fig. A.2

Optical coherence tomography (OCT) image (pre-IVL: Figure 2A) showing nodular calcification [asterisk (∗)] projecting into the vessel lumen. Post-IVL (Figure 2B), there is a fracture in the calcium [asterisk (∗)]. Post PCI, there is well apposition of DES to the vascular intima.

Fig. A.3

A: Coronary angiogram LAO cranial view showing 95% discrete stenosis with calcification in distal left main. B: Coronary angiogram LAO cranial view following IVL guided percutaneous coronary intervention (PCI) to distal left main showing less than 20% residual stenosis with TIMI III flow.

Fig. A.4

A: Coronary angiogram AP cranial view showing concentric calcification in mid LAD (black arrow). B: Coronary angiogram AP cranial view showing diffuse disease in mid and distal LAD with concentric calcification. C: Coronary angiogram AP cranial view post drug eluting stent (DES) implantation in mid and distal LAD following IVL with less than 50% residual stenosis and a Thrombolysis in Myocardial Infarction (TIMI) III flow. D: Optical coherence tomography (OCT) image pre-and post IVL showing concentric calcification with multiple calcium fractures (asterisk [∗]) following IVL.