IVUS-guided RotaShock PCI with SoniCracker for an eruptive calcified nodule in the left anterior descending artery: A challenging case report from Rajavithi Hospital, Thailand

Abstract

Severely calcified coronary lesions remain among the most challenging subsets in percutaneous coronary intervention (PCI). Calcified nodules are an uncommon but clinically important form of coronary calcification associated with device-delivery difficulty, stent underexpansion, procedural failure, and adverse outcomes. Rotational atherectomy modifies superficial calcium and facilitates device crossing but has limited ability to fracture deep calcium, whereas intravascular lithotripsy (IVL) can fracture deep calcium but may be difficult to deliver across tight, undilatable lesions. The aim of this case report was to describe a 72-year-old Thai man with chronic coronary syndrome and multivessel coronary artery disease who had a previously unsuccessful balloon angioplasty for a heavily calcified proximal-to-mid left anterior descending artery (LAD) lesion. One month later, staged PCI was performed using an intravascular ultrasound (IVUS)-guided RotaShock strategy. Rotational atherectomy with a 1.5-mm burr was performed first to facilitate device delivery. Post-atherectomy IVUS demonstrated extensive superficial and deep circumferential calcium with a prominent protruding calcific mass consistent with an eruptive calcified nodule phenotype. SoniCracker IVL was subsequently performed, producing multiple calcium fractures on repeat IVUS. Two drug-eluting stents were implanted and optimized under IVUS guidance, resulting in satisfactory stent expansion and apposition with a minimum stent area of 10.5 mm² and final Thrombolysis in Myocardial Infarction (TIMI) grade 3 flow without procedural complications. This case demonstrates the immediate technical feasibility of a complementary rotational atherectomy-plus-IVL strategy for a complex, balloon-undilatable calcified LAD lesion and illustrates the role of intravascular imaging in guiding sequential calcium modification.