Successful management of a calcified coronary nodule with intravenous lithotripsy: a case report and review of literature.

Abstract

Background: Calcified nodules within coronary stents are increasingly recognized as contributors to in-stent restenosis and stent thrombosis, which pose significant cardiovascular risks. Advanced imaging techniques, such as optical coherence tomography, have been crucial in detecting calcified nodules, which are more prevalent in patients undergoing hemodialysis and those with pre-existing calcified lesions.

Case presentation: A 67-year-old British man with a history of diabetes, hypertension, and heart failure presented with chest pain, dyspnea, and diaphoresis, leading to a diagnosis of non-ST-elevation myocardial infarction based on elevated troponin and B-type natriuretic peptide levels. Imaging revealed significant coronary artery disease, including a patent left anterior descending stent with focal stenosis due to a calcified nodule, chronic total occlusion of the left circumflex artery, and right coronary artery occlusion. The patient was treated with intravenous lithotripsy and balloon angioplasty, along with medical therapy, including dual antiplatelet therapy, statins, beta-blockers, angiotensin-converting enzyme inhibitors, and diuretics. The discussion highlights the challenges of managing calcified coronary lesions, comparing rotational atherectomy, intravenous lithotripsy, and conventional stenting techniques. While rotational atherectomy is effective for superficial plaque modification, intravenous lithotripsy offers deeper calcium modification with fewer complications, though both modalities require careful patient selection for optimal outcomes.

Conclusion: Calcified nodules within coronary stents are a significant cause of in-stent restenosis and thrombosis, leading to adverse cardiovascular events. Advanced imaging techniques such as intravascular ultrasound and optical coherence tomography are crucial for early detection and accurate diagnosis. Effective management of calcified nodule-related lesions remains challenging, with rotational atherectomy and intravenous lithotripsy emerging as viable adjunctive therapies for optimal stent expansion. This case highlights the successful use of rotational atherectomy in treating a patient with severe in-stent calcification presenting with non-ST-elevation myocardial infarction. A tailored approach combining advanced imaging, lesion preparation, and optimal stent deployment is essential for improving outcomes in patients with complex calcified coronary disease.