Case Report The use of Intra-Vascular Lithotripsy (Shock Wave Therapy) in a Severely Calcified RCA Lesion in a Patient With CABG - Status and Breast Cancer, Undergoing Chemotherapy
by Sokhrab Khorram*, Akhil Jith
Cardiology Department, RAK Hospital, Ras Al Khaimah, United Arab Emirates
*Corresponding author: Sokhrab Khorram, Cardiology Department. RAK Hospital, Ras Al Khaimah, United Arab Emirates
Received Date: 16 February, 2025
Accepted Date: 24 February, 2025
Published Date: 26 February, 2025
Citation: Khorram S, Jith A (2025) The use of Intra-Vascular Lithotripsy (Shock Wave Therapy) in a Severely Calcified RCA Lesion in a Patient With CABG - Status and Breast Cancer, Undergoing Chemotherapy. Cardiol Res Cardio vasc Med 10:276. https://doi.org/10.29011/2575-7083.100276
Abstract
Introduction: This is the case of a patient with acute coronary syndrome (ACS) and severely calcified RCA lesion with PCI and CABG status and undergoing chemotherapy for breast cancer. The use of the latest technology - intravascular lithotripsy (shock wave therapy) is effective in the treatment of such complex lesion in a patient with multiple risk factors and comorbidities. Case Presentation: We admitted a 69 -year-old female patient who presented with symptoms of severe recurrent chest pain on effort (NYHA class III). The patient is a known case of DMT2, essential hypertension, dyslipidaemia, PCI and CABG Status. She is also on chemotherapy for breast cancer. On admission her ECG and cardiac markers showed Non-STEMI, CAG showed severely calcified sub-occlusion of mid RCA (90-95%). Her LIMA graft to LAD was functional and patent. Previously – implanted stent in OM in the previous hospital was also patent with TIMI 3 flow. She had been refused PCI for calcified RCA lesion and was advised for CABG in the previous hospital. Conclusion: The present case illustrates that calcified coronary artery lesions present a significant challenge to PCI treatment, especially in a patient with PCI and CABG status in the past and undergoing chemotherapy for breast cancer at present. The use of intravascular lithotripsy (IVL) using shock waves is a novel and effective method in treating such complex cases.
Keywords: Chest pain, Non-STEMI, calcified lesion, CABG status, complex angioplasty, intravascular lithotripsy (IVL)
List of Abbreviations: ECG=Electrocardiogram; WBC=White blood cell; IVL=Intravascular lithotripsy; Hb=Haemoglobin; LAD=Left anterior descending; OM=Obtuse marginal; PCI=Percutaneous coronary intervention; CABG=Coronary artery bypass graft; HTN=Hypertension; DM=Diabetes Mellitus; IVUS=Intravascular lithotripsy; OCT=Optical coherence tomography; ICU=intensive care unit; TLR=Target lesion revascularization; DES=Drug eluting Stent; SC=semi - compliant; NC=Non – compliant
Introduction
Calcified coronary lesions constitute one of the main challenges in the cardiac catheterization laboratory, being present in up to one-third of patients undergoing percutaneous coronary intervention (PCI). The high prevalence is even increasing, considering the trend towards aging of the population and the presence of comorbidities such as diabetes and chronic kidney disease. PCI procedures in such patients are associated with lower procedural success and higher rates of periprocedural complications such as failure to deliver stents, perforations, dissections and other adverse cardiac events. Furthermore, suboptimal stent deployment in the setting of severe calcification is associated with both short and long – term major adverse cardiac events, including stent thrombosis, MI, in-stent restenosis and target lesion revascularization. A variety of treatment options for these lesions exist, including specialized balloons (cutting, scoring, OPN), atherectomy [3].
Intravascular lithotripsy (IVL) is the latest technology to treat calcified coronary lesions. It uses acoustic shock waves in a balloon-based delivery system to modify severely calcified atherosclerotic coronary vascular lesions in preparation for stent implantation (Figure 1). IVL results in circumferential and longitudinal calcium fracture, which improves transmural vessel compliance, and facilitates a better stent apposition as well as adequate stent expansion [1]. It induces fracture in deep-seated calcium, where rotational atherectomy often fails. Since calcium fragments remain in situ in IVL, there is no risk for distal embolization and slow flow in the coronaries [2].
Figure 1: IVL device generating acoustic shock waves with the balloon-based delivery system
Case Report
This is a 69 - year old female, who was seen in ER with symptoms of severe left-sided chest pain. The chest pain was there on and off for the past 7 days, but had increased significantly since the morning of the presentation day. The patient is a known case of DM T2, essential hypertension and dyslipidemia. She is also a known case of CAD, CABG status (2004), angioplasty status (2005). The patient is also diagnosed with breast cancer and is currently receiving chemotherapy.
Her initial vital signs revealed temperature 36.8 degrees C, pulse rate 77 beats per minute, Blood Pressure 114/60 mm Hg. Respiratory rate 18 cycles per minute. Oxygen saturation 100%, Pain Score 3/10.
Her ECG taken in the ER showed sinus rhythm with nonspecific T wave abnormalities in infero- lateral leads (Figure 2).
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