Severely calcified vessel with multiple calcified nodules treated with a leave-nothing-behind- strategy using DCB after multi-modal lesion preparation

Introduction: Percutaneous coronary intervention (PCI) of eruptive calcified nodules with drug-eluting stents is associated with high revascularization rates. This case report presents the treatment of a severely calcified right coronary artery (RCA) with multiple calcified nodules using a "leave-nothing-behind" strategy with drug-coated balloons (DCB) combined with a multimodal lesion-preparation approach.

Case description: An 80-year-old male with a complex cardiovascular history, including previous PCI of the LAD and RCA, as well as coronary artery bypass grafting (CABG) with LIMA to the LAD and a vein graft to the PDA, presented for elective PCI due to exertional dyspnea and chest pain. Coronary angiography revealed severe stenoses of the RCA, with multiple eruptive calcified nodules and a distal bifurcation lesion (Medina 1,1,1) (Figure 1). Baseline optical coherence tomography (OCT) images were not obtainable, as the imaging catheter could not pass the stenosis. After 3 runs of rotablation (RA) (1.5mm), a 4.0mm IVL-balloon was used for the distal and mid-sections of the RCA, followed by the acquisition of OCT-images. First, the ostial, proximal and mid-sections of the RPL were treated using NC-balloons. Afterwards, the RPD was rewired, the ostial segment was treated using cutting balloons followed by dilation of the RPD-ostium using NC ballons and DCBs. Lastly, extensive DCB treatment of segment 2 and 3 in the RCA was conducted using 4.0x20mm and 30mm DCBs, inflated for 90 seconds in combination with NC-ballons resulting in an angiographically successful intervention. Follow-up angiography after six months demonstrated patent vessels with no evidence of restenosis. OCT confirmed sufficient minimal lumen area both proximally and distally post-intervention (Figure 2). The patient reported significant improvement in symptoms.

Discussion: This case highlights the utility of DCBs in treating heavily calcified coronary lesions, particularly in the presence of calcified nodules. The combination of RA, intravascular lithotripsy (IVL), and cutting balloons optimized lesion preparation, ensuring favorable outcomes with the DCB approach. Though the use of DCBs in calcified nodules remains to be validated in randomized controlled trials, this strategy may serve as a safe alternative to stenting, offering a viable solution for complex coronary artery disease.

Conclusion: DCBs, when used after adequate lesion preparation, may provide a safe and effective alternative for managing severely calcified complex coronary artery disease, particularly in patients with calcified nodules.