Intravascular lithotripsy for stent under‐expansion: Panacea or Pandora's box?

Abstract

Balloon undilatable lesions are common and can be challenging to treat, especially within stents, and require a systematic, algorithmic approach.

Coronary laser with simultaneous contrast injection for the treatment of stent underexpansion

“…Intravascular lithotripsy delivers a pulsatile sonic pressure wave via a balloon positioned within the coronary artery with the ability to fracture intimal and medial calcification and energy passing atraumatically through the surrounding noncalcified tissue [ 19 ]. IVL has been used as an off-label technique to treat underexpanded stents with promising results [ 6 ], although in some severe underexpanded cases, the placement of balloon lithotripsy can be challenging [ 3 ], such as in a case illustrated in the present series ( Fig. 3 ).…”

“…Stent underexpansion is associated with a higher risk of stent thrombosis and restenosis [ 1 , 2 ]; therefore, ensuring adequate lesion debulking is crucial for optimal stent deployment. Some balloon undilatable lesions are easily identified under fluoroscopy by visualizing a waist in the balloon; however, at other times, a precise diagnosis requires intravascular imaging [ 3 ]. Indeed, optimal stent expansion using intravascular ultrasound (IVUS) has been associated with lower target vessel revascularization compared with angiographic guidance alone [ 4 ].…”

Stent-in-stent underexpansion shockingly tackled with shockwave intravascular lithotripsy in the acute setting

“…The shockwave intravascular lithotripsy (Shockwave Medical, Santa Clara, California, USA) was implemented as an off-label bail-out option for refractory multiple-layer DES underexpansion [1]. The intravascular lithotripsy catheter was delivered across the diseased OM1 and the integrated balloon (4 × 12 mm) was inflated to 4atm at the stenosis’ epicenter (Video 9, Supplemental Digital Content 9, http://links.lww.com/MCA/A549).…”