A 73-year old man was found to have proximal left anterior descending (LAD) in-stent stenosis (ISS) secondary to stent underexpansion as a cause of limiting angina. Despite serial dilations, including 3.5 mm OPN NC^® High-Pressure PTCA (SIS Medical AG; Switzerland) to >40 atm, percutaneous coronary intervention (PCI) was unsuccessful on multiple occasions (Panel A). In September 2018, the patient re-presented with recurrent angina, and angiography identified a high-grade proximal LAD lesion (Panel B, Supplementary material onlineSupplementary material online, Video S1). Optical coherence tomography (OCT) confirmed severe ISS with minimal stent area (MSA) 1.09 mm² secondary to stent underexpansion due to concentric severe coronary calcification (Panel C–F, Supplementary material onlineSupplementary material online, Video S2). A C2 4.0 × 12 mm Shockwave (Fremont, CA, USA) intravascular lithotripsy (IVL) balloon was advanced across the lesion and inflated to 4 atm. During the second round of 10 pulses, the balloon fully expanded (Panel G, Supplementary material onlineSupplementary material online, Video S3). Angiography confirmed successful PCI with minimal residual diameter stenosis (Panel H, Supplementary material onlineSupplementary material online, Video S4). Repeat OCT showed multiple calcium fractures at the site of ISS, with post-IVL stent area of 6.47 mm² (Panel I–L, Supplementary material onlineSupplementary material online, Video S5). The procedure was completed using a 4.0 × 15 mm drug-eluting balloon (SeQuent, B Braun) without additional DES placement and a final stent area of 6.55 mm² at the site of previous MSA. IVL is a new technology, in which multiple lithotripsy emitters mounted on a traditional catheter platform deliver localized pulsatile sonic pressure waves liberating extreme bursts of energy. We illustrate treatment of high-grade ISS secondary to severe coronary calcification with IVL for the first time, where historically there have been limited treatment options.

中文翻译：

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血管内碎石术治疗严重冠状动脉钙化继发的支架扩张不足。

一名73岁的男性被发现患有扩张性支架扩张不足引起的近端左前降支（LAD）支架内狭窄（ISS），这是限制心绞痛的原因。尽管连续扩张术，包括3.5毫米OPN NC ^®高压PTCA（SIS医疗AG，瑞士）到> 40个大气压，经皮冠状动脉介入治疗（PCI）是在多个场合（图A）不成功。在2018年9月，患者再次出现了复发性心绞痛，血管造影发现了高度近端LAD病变（图B，在线补充材料在线补充材料，视频S1）。光学相干断层扫描（OCT）证实为严重ISS，支架面积（MSA）最小为1.09 mm ²继发于同心严重冠状动脉钙化引起的支架扩张不足（面板CF，在线补充材料，在线补充材料，视频S2）。一个C2 4.0×12 mm Shockwave（美国加利福尼亚州弗里蒙特市）血管内碎石术（IVL）球囊穿过病灶前进并充气至4个大气压。在第二轮10脉冲期间，气球完全展开（面板G，在线补充材料在线补充材料，视频S3）。血管造影证实PCI成功，残留直径狭窄最小（H组，在线补充材料在线补充材料，视频S4）。重复OCT显示在ISS部位有多处钙骨折，IVL后支架面积为6.47 mm ²（面板I–L，在线补充材料，在线补充材料，视频S5）。使用4.0×15 mm的药物洗脱球囊（SeQuent，B Braun）完成该程序，而无需额外的DES放置，并且在先前的MSA部位的最终支架面积为6.55 mm ²。IVL是一项新技术，在该技术中，安装在传统导管平台上的多个碎石术发射器可传递局部搏动声波压力波，从而释放出能量的极端爆发。我们首次说明了用IVL治疗继发于严重冠状动脉钙化的继发性高位ISS，而在历史上，这种治疗方法有限。