Coronary Lithotripsy: 7 Proven Rules for Safer Global Care
Coronary lithotripsy has changed how we prepare heavily calcified vessels, yet the device, imaging catheter and pump that make an ostial left main case manageable in one cath lab may be missing in the next. Using one planning-stage case, here are seven rules for safer care when the toolkit is only partly on the shelf, with the strength of evidence behind each one stated as we go.
The case we are planning
A 75-year-old woman with an ejection fraction of 60% has already had PCI to the mid RCA, which now becomes her lifeline during every left main occlusion. The left main carries 360-degree calcium from ostium to distal end, with a reference diameter near 4.5 mm. The mid LAD has an 80% lesion and the proximal circumflex a 90% lesion.
Nothing has been done yet. In a fully equipped centre the plan reads: IVUS first, coronary lithotripsy as the main calcium tool, a rehearsal inflation, then careful ostial stent optimisation. The rules ask what changes when a piece is absent.
Rule 1: Know where the coronary lithotripsy evidence was generated
Most of the evidence cited here comes from well-resourced European and US centres. The randomised comparisons with rotational atherectomy, ROLLER COASTR-EPIC22 from Spain and ICARE OFDI from France, found coronary lithotripsy non-inferior for stent expansion and minimal stent area. Neither enrolled the left main; ROLLER COASTR studied 2.5–4.0 mm vessels, and ICARE required lesions crossable with a 2.0 mm balloon.
Men made up three-quarters or more of these trial populations. Our patient is a woman with a 4.5 mm left main and a true aorto-ostial lesion, outside every enrolment envelope. Left main data for coronary lithotripsy are registries and case reports only; no randomised trial of IVL against rotablation has included this segment.
Because these randomised trials did not include the left main, any left main recommendation is extrapolated. When you apply the findings to your own population, ask a structural question: how closely do your patients, vessels and lesions resemble those enrolled? Where they differ, lean harder on imaging, test manoeuvres and heart-team review.
Rule 2: Without IVUS, let the balloon speak, and call it second-best
IVUS is my first choice here; OCT is unreliable at a true aorto-ostial lesion because blood cannot be cleared consistently from the aortic side. IVUS shows calcium arc and length, two of the three variables in the OCT-derived Fujino score, where lesions scoring 4 reached a mean stent expansion of 78%, against 96% for lower scores.
Without IVUS, three substitutes help, none equivalent. A dilatability test with an undersized 3.0 mm non-compliant balloon to about 12 atm: a persistent waist means a plain balloon strategy is likely to fail and coronary lithotripsy is needed. Angiographic cues: radio-opacity on both walls before contrast suggests circumferential calcium. And staging: diagnose today, treat later with imaging arranged by referral.
Record this pathway as second-best, because a balloon cannot map calcium arc and length or measure final stent area.
Rule 3: When coronary lithotripsy is not stocked
Where coronary lithotripsy is unavailable, the realistic options are rotational atherectomy started with a small burr and stepped up (1.75 mm through a 7F guide) before high-pressure non-compliant dilatation, or referral. Rotablation mainly modifies superficial calcium, so check the balloon expands fully before stenting. Rotablation is non-occlusive, but diffuse left main calcium raises the risk of slow flow or no-reflow, a global ischaemia you cannot switch off.
Modified balloons alone are often insufficient: in PREPARE-CALC they reached their goal in 81 of every 100 patients, rotablation in 98. A cutting balloon at a circumferentially calcified ostium also risks dissection into the aortic root.
Orbital atherectomy is not the substitute. Its crown needs room to orbit, and at the aorto-ostium the guide is unstable and sanding turns eccentric. ECLIPSE, with 2,005 patients, showed no gain over balloon preparation: minimal stent area 7.67 against 7.42 mm², one-year target vessel failure 11.5% against 10.0%. Excimer laser stays a bail-out.
Rule 4: Without on-site MCS, the test inflation makes coronary lithotripsy safer
Each cycle of coronary lithotripsy occludes the left main for 15 to 20 seconds, much like any non-compliant inflation during left main stenting. Before the first pulse I rehearse it: a 3.0 × 8–12 mm non-compliant balloon, held for the same time with the guide disengaged into the aorta. I record the pressure nadir, ST change, arrhythmia, symptoms and recovery time.
If pressure holds and recovery takes under 30 to 60 seconds, she can proceed without support. A marked fall, ventricular tachycardia or slow recovery changes the plan, and where no pump exists on site, that is the moment to stop, stage and arrange transfer to a centre with support.
If she tolerates it, deliver coronary lithotripsy in short cycles: mean pressure above 80–85 mmHg before each run, pressors and atropine drawn up, pads on, a circumflex buddy wire and an ACT above 250–300 seconds. Wait for real recovery, often 30 to 90 seconds, not just the 10-second minimum pause in the instructions. Salazar, Escaned and colleagues used five-pulse runs in women aged 91 and 94, without support.
The registries support this in selected patients. In the BENELUX-IVL left main analysis, patients were older (median 79) with lower ejection fractions (median 41%) than the comparison group, yet only 6.8% received mechanical support; technical success was 93.2%, and cardiac death and MACE were comparable to one year. Kosowski’s 85-year-old woman with an ostial left main lesion received 80 pulses without instability or support.
A JSCAI systematic review of 148 patients from 15 studies, mostly distal disease, reported success from 86.4% to 100% and angiographic complications of 3.4%, with no randomised data. Support was chosen for contrasting reasons elsewhere: Sinning’s patient had an LAD CTO plus bifurcation complexity, Chaddad’s an ejection fraction of 25%. I still place a 6F femoral sheath under ultrasound for bail-out.
Rule 5: Choose guides and access that standard inventory supports
My guide is an EBU 3.5 in 7F without side holes, which most labs stock. It gives the backup to cross the left main and deliver stents to the mid LAD and circumflex; a JL gives too little. I prefer 3.5 because older women tend to have smaller aortic roots, where a 4.0 sits poorly and engages deeply. Avoid an AL1, and fix damping by repositioning.
7F allows kissing with 4.0 and 3.0–3.5 balloons, two wires plus IVUS, or a 1.75 mm burr; 6F takes burrs only to 1.5 mm, though the coronary lithotripsy catheter itself fits 6F. Femoral 7F under ultrasound adds support and a route for bail-out devices; radial works with a 7F slender sheath if ultrasound shows at least about 2.3 mm. Engage to image, disengage to treat.
Rule 6: Optimise the stent against aorto-ostial recoil
The largest coronary lithotripsy balloon is 4.0 × 12 mm, about 0.9 of this reference, and the instructions advise the largest size when 1:1 is impossible. Therapy runs at 4 atm; pulsing at higher pressure for apposition is off-label. Plan two positions, ostial with 1–2 mm in the aorta and the distal body, within 80 pulses per segment and 120 per catheter.
Recoil is the enemy. In the BENELUX-IVL aorto-ostial analysis, device success was near complete, yet residual stenosis under 30% was reached less often at the ostium, 81.3% against 90.5%, and in-hospital MACE was 4.2% against 0.7%, all cardiac deaths. Coronary lithotripsy fractures calcium; it does not hold an ostium open.
After coronary lithotripsy, confirm fracture with a 4.5 mm non-compliant balloon, choose a DES that expands to 4.0–4.5 mm, protrude 1–2 mm into the aorta, post-dilate hard, perform POT with a 5.0 balloon and flare the ostium. The 8.2 mm² threshold used by Sandesara is a floor; I aim for 12–13 mm², roughly 80–90% of reference. If the circumflex ostium is diseased, plan DK-crush or culotte.
Rule 7: Have the heart-team conversation, whatever the health system
Isolated left main disease with a low SYNTAX score has fared comparably with PCI and CABG in EXCEL and NOBLE. This patient has left main, LAD and circumflex disease after RCA PCI, so the heart team should meet first and weigh her anatomy, frailty and wishes.
Capital equipment such as a coronary lithotripsy generator or rotablation console, plus single-use catheters and burrs, decides whether a centre can offer a technique at all. I give no cost figures because they vary from country to country. Tell the patient which options exist locally and which need transfer, and agree that pathway in advance.
Coronary lithotripsy across resource settings: a quick guide
| If missing | Second-best path | What you give up |
|---|---|---|
| IVUS | Dilatability test, angiographic cues, staging | Calcium arc and length, final stent area |
| Coronary lithotripsy | Small-burr rotablation plus NC balloon, or referral | Lower slow-flow risk |
| On-site MCS | Test inflation, short cycles, transfer plan | Immediate rescue |
Explore more global case discussions on the World Elite Doctors blog, and structured study through the interventional cardiology courses and the cardiology learning centre.
References
- Jurado-Román et al. ROLLER COASTR-EPIC22. JACC Cardiovasc Interv. 2025;18:606-618. doi:10.1016/j.jcin.2024.11.012
- Honton et al. ICARE OFDI. EuroIntervention. 2026;22(15):e808-e819. doi:10.4244/EIJ-D-26-00426
- Abdel-Wahab et al. PREPARE-CALC. Circ Cardiovasc Interv. 2018;11:e007415. doi:10.1161/CIRCINTERVENTIONS.118.007415
- Kirtane et al. ECLIPSE: orbital atherectomy versus balloon angioplasty. Lancet. 2025. doi:10.1016/S0140-6736(25)00450-7
- Fujino et al. OCT-based calcium scoring. EuroIntervention. 2018;13:e2182-e2189. doi:10.4244/EIJ-D-17-00962
- Oliveri et al. Left main lithotripsy in BENELUX-IVL. Int J Cardiol. 2025;423:132996. doi:10.1016/j.ijcard.2025.132996
- Oliveri et al. Aorto-ostial lithotripsy in BENELUX-IVL. Catheter Cardiovasc Interv. 2024. doi:10.1002/ccd.31233
- Kosowski et al. Ostial left main lithotripsy (case). Kardiol Pol. 2022;80(4):489-490. doi:10.33963/KP.a2022.0033
- Salazar et al. Distal left main lithotripsy in very elderly women. JACC Case Rep. 2019;1(1):46-49. doi:10.1016/j.jaccas.2019.05.008
- Systematic review of left main lithotripsy. JSCAI. 2023. JSCAI full text
- Sandesara et al. Calcified distal left main PCI. Catheter Cardiovasc Interv. 2023. doi:10.1002/ccd.30855
- Sinning et al. Protected left main PCI (case). Eur Heart J Suppl. 2026. doi:10.1093/eurheartjsupp/suag004
- Chaddad et al. Left main PCI with Impella (case). Int J Surg Case Rep. 2025. doi:10.1016/j.ijscr.2025.111386
- Shockwave Medical. C2+ coronary IVL catheter IFU. IFU (PDF)
