Treatment of a Severely Calcified Ostial Stenosis in the Circumflex Artery Without Stent Implantation

Author
Dr. Irzal Hadžibegović

Introduction

Calcified ostial lesions in the circumflex artery (LCx) represent a significant challenge in percutaneous coronary intervention (PCI). In these cases, proper lesion preparation with specialized devices is crucial to optimize outcomes, and in patients with a high risk of bleeding, the 'leave nothing behind' strategy may be a viable alternative to stent implantation.

Patient Profile

Male, 75 years old.

Cardiovascular History:

  • Ischemic heart disease treated in 2011 with coronary bypass (LIMA-LAD) due to severe calcified stenosis in the distal left main and proximal LAD.
  • Implantable cardioverter-defibrillator (ICD) implanted in 2023 for primary prevention due to LVEF of 30%.

Current Presentation:

  • Progressive angina (CCS III) since September 2024.
  • On rivaroxaban treatment for chronic atrial fibrillation.
  • Total occlusion of the native LAD, with a patent LIMA-LAD graft.
  • Subtotal calcified stenosis in the circumflex artery (LCx).
  • Right coronary artery without significant lesions.

Procedure

Access and Lesion Characterization

  • The procedure was performed via a left radial approach.
  • An initial attempt to cross the lesion with a hydrophilic floppy guidewire was unsuccessful.

Lesion Preparation with Specialized Devices

  • A Navitian microcatheter was advanced to exchange for a higher support guidewire.
  • Pre-dilation was performed with a non-compliant (NC) balloon (2.5x15 mm).
  • Attempted dilation with an ultra-high-pressure (OPN) balloon (3.0x15 mm) at 40 atm failed to fracture the calcium.
  • Intravascular lithotripsy (IVL) was performed using a 3.5 mm Shockwave balloon, successfully fracturing the stenosis after the seventh application.
  • Further lesion modification was achieved with a 3.5x15 mm Naviscore scoring balloon, creating cuts and fenestrations in the calcified plaque.
  • Final treatment was completed without stent implantation, using a sirolimus-eluting balloon (Selution 3.5x30 mm) inflated for 60 seconds.

Final Outcome

  • Final angiography showed a satisfactory result, with a residual stenosis of 30% and TIMI 3 flow in the LCx.
  • The patient experienced no complications or recurrent chest pain.
  • Hospital discharge was given after 3 days, with prescribed treatment including clopidogrel 75 mg (4 weeks) and rivaroxaban 15 mg.
  • Pre-discharge stress test (METT 6) showed no inducible angina.

Conclusion

In this case of severe ostial and calcified stenosis in the circumflex artery, the combination of advanced devices allowed for effective lesion treatment without the need for stent implantation. The use of IVL for calcium fracture, followed by a cutting balloon and a drug-coated balloon, provided a satisfactory outcome while avoiding prolonged dual antiplatelet therapy in a patient with a high risk of bleeding.

Figures
Figure 1. Initial angiography of the circumflex artery
Figure 1. Initial angiography of the circumflex artery
Figure 2. Initial attempt to cross the lesion
Figure 2. Initial attempt to cross the lesion
Figure 3. Support optimization with Navitian microcatheter
Figure 3. Support optimization with Navitian microcatheter
Figure 4. Dilatation with OPN 3.0x15 mm balloon at 40 atm
Figure 4. Dilatation with OPN 3.0x15 mm balloon at 40 atm
Figure 5. Intravascular lithotripsy (IVL) with Shockwave 3.5 mm balloon
Figure 5. Intravascular lithotripsy (IVL) with Shockwave 3.5 mm balloon
Figure 6. Lesion modification with cutting balloon
Figure 6. Lesion modification with cutting balloon
Figure 7. Inflation of drug-coated balloon
Figure 7. Inflation of drug-coated balloon
Figure 8. Final angiography with satisfactory result
Figure 8. Final angiography with satisfactory result
Publication date