JACC: CARDIOVASCULAR INTERVENTIONS
VOL. 10, NO. 3, 2017
ª 2017 BY THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION.
ISSN 1936-8798/$36.00
PUBLISHED BY ELSEVIER. ALL RIGHTS RESERVED.
http://dx.doi.org/10.1016/j.jcin.2016.11.048
A Calcific, Undilatable Stenosis Lithoplasty, a New Tool in the Box? Kalpa De Silva, MBBS, PHD, James Roy, MD, Ian Webb, MA, PHD, Rafal Dworakowski, MD, PHD, Narbeh Melikian, BSC, MD, Jonathan Byrne, MBBS, PHD, Philip MacCarthy, BSC, MBBS, PHD, Jonathan Hill, MA
A
69-year-old man with established coronary artery disease and left ventricular dysfunction (ejection fraction, 40%) with typical
F I G U R E 1 Pre-Percutaneous Coronary Intervention
Angiogram
Canadian Cardiovascular Society class III angina underwent percutaneous coronary intervention (PCI) for severe diffuse calcific disease in the right coronary artery (Figure 1). The vessel was prepared with
2.5-mm and 3.0-mm balloon pre-dilation. However, despite the use of 3.0-mm noncompliant balloon, there was inadequate balloon expansion with a “dog-bone” appearance observed (Figure 2). The patient was readmitted for a further attempt at PCI with adjunctive lithoplasty for calcium debulking. A 3.5 12 mm Lithoplasty balloon (Shockwave Medical, Fremont, California) was the initial and only balloon used to pre-dilate and treat the entire length of disease. Briefly, the Lithoplasty technique involves inflating the balloon to low pressure (4 atm) with 8 pulses of ultrasound energy of 10 s delivered per balloon. A degree of balloon deformation was observed secondary to a region of lesion constriction, at the nominal pressure of 4 atm, the Lithoplasty was initiated, with the balloon seen to inflate fully at this low pressure. The balloon is then inflated to 6 atm for 15 to 20 s after each pulse to maximize balloon expansion and aid removal of debris. Lithoplasty
From the Cardiology Department, King’s College Hospital NHS Trust, London, United Kingdom. All authors have reported that they have no relationships relevant to the contents of this paper to disclose. Manuscript received October 26, 2016; revised manuscript received November 28, 2016, accepted November 30, 2016.
De Silva et al.
JACC: CARDIOVASCULAR INTERVENTIONS VOL. 10, NO. 3, 2017 FEBRUARY 13, 2017:304–6
PCI With Adjunctive Lithoplasty
F I G U R E 2 “Dog-Bone” of Noncompliant Balloon
Red arrow shows ’dog-bone’ defect of balloon.
preferentially allows calcium modification without
3.5 22 and 4.0 16 mm drug-eluting stent with a
affecting the endovascular soft tissue, and sub-
good OCT (Figure 4, Online Video 2) and angiographic
sequently aids stent delivery and optimization. Opti-
(Figure 5) result.
cal coherence tomography performed pre-lithoplasty
Calcific coronary disease remains an important
and post-lithoplasty showed the “calcium cracking”
cause of stent under-expansion and represents a nidus
effect of the technique (Figure 3, Online Video 1).
for stent thrombosis. Revascularization undertaken in
The segment of disease was then treated with a
those >75 years, a cohort with increased coronary
F I G U R E 3 Optical Coherence Tomography Showing “Calcium Cracking” After Lithoplasty
See Online Video 1.
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306
De Silva et al.
JACC: CARDIOVASCULAR INTERVENTIONS VOL. 10, NO. 3, 2017 FEBRUARY 13, 2017:304–6
PCI With Adjunctive Lithoplasty
F I G U R E 4 Coregistered Angiogram/Optical Coherence Tomography Result Post-Percutaneous Coronary Intervention
See Online Video 2.
F I G U R E 5 Final Angiographic Appearance
calcification, now accounts for 25% to 30% of all PCI procedures (1). Current techniques to modify calcific stenoses include standard or high-pressure noncompliant balloons, cutting/scoring balloons, or rotational atherectomy. High-pressure balloon treatment may lead to localized wall injury, which may provide a vascular substrate for restenosis, with this and rotational atherectomy also increasing the risk of coronary perforation (0.7% with rotational atherectomy vs. 0.1% in standard procedures) (2). Lithoplasty may provide an adjunct to PCI that provides focal calcium modification with limited localized injury to the endovascular surface while aiding stent delivery and expansion.
ADDRESS FOR CORRESPONDENCE: Dr. Jonathan
Hill, King’s College Hospital, Denmark Hill, London SE5 9RS, United Kingdom. E-mail:
[email protected].
REFERENCES 1. Vandermolen S, Abbott J, De Silva K. What’s age got to do with it? A review of contemporary revascularization in the elderly. Curr Cardiol Rev 2015;11:199–208.
2. Cohen BM, Weber VJ, Reslman M, Casale A, Dorros G. Coronary perforation complicating rotational atherectomy: the U.S. multicenter experience. Cathet Cardiovasc Diagn 1996;(Suppl 3):55–9.
KEY WORDS calcification, lithoplasty, undilatable stenosis AP PE NDIX For supplemental videos and their legends, please see the online version of this article.
