Clinical Images

Shockwave Lithotripsy vs Rotational Atherectomy: Mechanistic Differences From Optical Coherence Tomography

Ota Hlinomaz, MD, PhD1;  Miloslav Tejc, MD2;  Mahmoud Sabbah, MD, PhD1,3

Ota Hlinomaz, MD, PhD1;  Miloslav Tejc, MD2;  Mahmoud Sabbah, MD, PhD1,3

J INVASIVE CARDIOL 2021 January 7 (Epub Ahead of Issue).

Key words: coronary calcification, optical coherence tomography, rotational atherectomy, shock wave lithotripsy

A 63-year-old man presented with a non-ST segment elevation myocardial infarction. He was referred to our hospital for percutaneous coronary intervention (PCI) with rotational atherectomy (RA) after an attempted PCI that was unsuccessful due to a severely calcified undilatable lesion (Figure 1A). The procedure was performed through the right radial approach with a 7.5 Fr sheathless AR2 guiding catheter. Multiple series for the lesion preparation and predilation were attempted, first using 1.5 mm and then 1.75 mm Rota burr (RotaLink Plus; Boston Scientific) followed by sequential non-compliant balloon dilations with several high-pressure, super-high-pressure, and scoring balloons. All failed to properly dilate the lesion, resulting in a dog-boning effect (Figure 1B, small inset), and the procedure was terminated due to a large contrast volume and high radiation dose. Two weeks later, the Shockwave C2 intravascular lithotripsy (IVL) system (Shockwave Medical) was used with a 3.5 x 12 mm balloon, delivering 8 series of lithotripsy shocks followed by effective balloon dilation with a non-compliant balloon (Figure 1C) and successful implantation of 2 overlapping drug-eluting stents (Figure 1D). Interrogation of optical coherence tomography (OCT) (DragonFly Optis imaging catheter, Abbott Medical) before and after lithotripsy balloon application offered a beneficial insight into the differential mechanistic effect of RA versus the IVL balloon. Both RA and non-compliant, high-pressure balloons failed to interfere with the thick, deep calcification sheets that were exceptionally stiff (Figures B1 and B2; Video 1), but the lithotripsy balloon effectively created multiple fissures and microexplosions up to the thick, deep calcium layer (Figures C1 and C2, white arrows; Video 2) and provided a suitable platform for appropriate lesion dilation and successful stent deployment without underexpansion or malposition (Figures D1 and D2). This case highlights that RA is merely paving the road and may help in superficial calcifications. It also showed the useful role of OCT for guiding the appropriate treatment strategy. Interrogation with OCT in angiographically visible severe calcification could save time, effort, radiation exposure, and contrast, as well as a lot of procedural costs. IVL offers a novel option for lesion preparation of severely calcified and undilatable de novo lesions and could be an appropriate alternative for RA.

From the 1Department of Cardioangiology, International Clinical Research Center, St. Anne's University Hospital Brno, Czech Republic; 2the Department of Cardiology, Kardiocentrum Vysocina, Jihlava, Czech Republic; and 3the Department of Cardiology, Faculty of Medicine, Suez Canal University, Ismailia, Egypt.

Disclosure statement: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. The authors report no conflicts of interest regarding the content herein.

The authors report that patient consent was provided regarding use of the images herein.

Final version accepted March 23, 2020.

Address for correspondence: Mahmoud Sabbah, MD, PhD, FESC, FSCAI, Department of Cardioangiology, International Clinical Research Center, St. Anne's University Hospital, Pekařská 53/656, 91, Brno, Czech Republic. Email: