Bail-out therapy in ST-segment elevation myocardial infarction due to calcified lesion causing stent underexpansion: Intravascular lithotripsy is in the lead.

A 52-year-old male was referred for an acute anterior ST-segment elevation myocardial infarction (STEMI). Coronary angiography revealed an acute left anterior descending artery occlusion. The patient was treated with a drug-eluting stent (DES). Despite long and repeated high-pressure inflations (>20 atm) of non-compliant balloons, OPN NCⓇ high-pressure balloon (SIS Medical AG; Frauenfeld, Switzerland), rotational atherectomy, and cutting balloon, there was a severe hourglass stent underexpansion caused by coronary calcification. Thus, intravascular lithotripsy (IVL) (Shockwave Medical, Fremont, CA, USA) was attempted to re-dilate this calcified lesion. Underexpansion was successfully treated after delivering 70 shockwaves to the narrowest segment. IVL delivers localized pulsatile sonic pressure waves inducing circumferential calcium modification and multiple fractures. Our observation illustrates the additional value of coronary lithotripsy as a bail-out procedure to tackle severely calcified, de novo coronary lesions causing stent underexpansion in the context of STEMI, when all other available techniques failed. <Learning objective: Severe coronary calcification may impair device delivery, stent apposition, and inhibit expansion, thus predisposing to stent thrombosis. Intravascular lithotripsy delivers localized pulsatile sonic pressure waves inducing circumferential calcium modification and multiple fractures. Our observation illustrates the additional value of coronary lithotripsy as a bail-out procedure to tackle severely calcified, de novo coronary lesions causing stent underexpansion in the context of ST-segment elevation myocardial infarction, when all other available techniques failed.>.