Orbital Atherectomy for Calcified Nodules Following Insufficient Deformation by Intravascular Lithotripsy

A 60-year-old man with diabetes mellitus presented to the hospital with chronic coronary syndrome. Coronary angiography (CAG) revealed a severely calcified lesion in the proximal right coronary artery (RCA) (Figure A). After low-profile balloon dilatation, optical coherence tomography (OCT) showed calcified nodules (CNs) in the proximal RCA (Figure B) and the proximal reference lumen diameter was 3.5 mm.

It was decided to use a 3.5-mm intravascular lithotripsy (IVL) balloon (Shockwave C2; Shockwave Medical, Inc.) to modify the calcified components (Figure C). However, even after 80 pulses, the IVL balloon expansion was insufficient (Figure D and E). Since further lumen gain was unlikely to be  achieved with modified balloon dilatation, orbital atherectomy (OA) was performed with the Diamondback 360 system (Abbott) at low- and high-speed rotations (Figure F).

Post-OA OCT revealed significant debulking of calcium at the CN site (Figure G and H). The lesion was predilated with a 3.5-mm scoring balloon, and acceptable lumen enlargement was obtained (Figure I-K). Subsequently, a 3.5 × 23 mm drug-eluting stent was deployed and postdilated with a 4.5-mm noncompliant balloon because the vessel diameter in the mid-portion of the lesion was 4.5 mm on OCT imaging. (Figure L). The final CAG and OCT images showed acceptable stent expansion (Figures M and N), and no cardiovascular events occurred 3 months after the procedure.

The management of heavily calcified lesions with CNs remains challenging.¹ Although the efficacy of IVL for CNs has been previously reported, approximately one-fourth of CNs are not deformable after IVL.² To the best of our knowledge, this is the first case report demonstrating successful OA modification of CNs after insufficient IVL treatment.