A male, 77 years old with Exertional chest pain for 4 months admitted to our department.CV history: No DM/HBP, No smoking. Pre-Angiograms finished three months ago: LAD: severe calcification, proximal LAD with stenosis of about 90%,  LCX:  stenosis of about 70-80%, RCA severe calcification, subtotal occlusion at the proximal segment; LAD to RCA distal collateral. Aspirin enteric-coated tablets (Bayaspirin Enteric-coated) 100mg/d, Clopidogrel (Plavix) 75mg/d, and Atorvastatin 20mg/d.

Renal function: BUN 6.00mmol/L，Cr: 73.7ummol/L, Glomerular Filtration Rate: 86.7ml/min, Blood glucose：6.26mmol/L, LDL：1.39mmol/L, CK-MB <2.0 ng/ml, Troponin I <0.010 ng/mlWhole blood count: Normal, Echocardiogram: LV size normal, EF: 66%, ECG: Normal Sinus rhythm.

LAD: severe calcification, proximal LAD with stenosis of about 90%,  LCX:  stenosis of about 70-80%, RCA severe calcification, subtotal occlusion at the proximal segment; LAD to RCA distal collateral. 

IM000009.avi
IM000010.avi

We used 7French AL 0.75 (Cordis) guiding to engage the RCA. And then implanted temporary pacemake lead (5F Medtronic) to the apic of  right ventricle. We sent one Sionblue 0.014" guidewire (ASAHI) to the distal of the RCA, and then used Corsair Microcatheter (ASAHI) to change Rotawire drive floppy (Bostonscientific) to the distal of the RCA. Used  1.25 mm Burr (Bostonscientific) to do atherectomy with 160 -180 K/minute from proximal to the distal of RCA. And examed the lesion by intravascular ultrasound (IVUS, Bostonscientific) found there were 360 degree calcification lesions, minimum lumen area (MLA) 3.23 mm square. Sent 3.0 x12 mm Intravascular Lithotripsy (IVL) balloon to the distal of RCA by the support with 6 French Guidezilla (Bostonscientific). Used 60 pulses of IVL from distal to the proximal of RCA. And then implant distal stent by 2.5 x 32mm (Bostonscientific, Promus PREMIER), middle stent 3.0 x 32mm (Bostonscientific, Promus PREMIER), and 3.5 x 28mm stent (Bostonscientific, Promus PREMIER) at proximal RCA. Post dilated the stents by 2.75 x 12mm, 3.0 x 12mm, 3.5 x 12mm, 4.0 x 12mm NC balloon (Bostonscientific, NC EMERGE). Repeat IVUS exam and final angiogram shown a good result. 

IM000017.avi
IM000035.avi
IM000058.avi

Intravascula lithotripsy (IVL) has a low learning curve and is easy to master; It is safer, shorten procedure time and more efficient than rotablation teachnique. It is effective for both superficial and deep calcifications. IVL make impossible lesions to do PCI become to possible. Sometimes, in very complex case, we need to combine rotablation and IVL to get good result.