Case 178: Manual of PCI - In-stent undilatable lesion

A patient with prior mechanical AVR and CABG and cardiomyopathy presented with angina. The LIMA to LAD was occluded and the culprit lesion appeared to be a 90% mid LAD in-stent lesion. The lesion would not expand despite inflating a 3.0 mm NC balloon at 26 atm. Intravascular lithotripsy with 100 pulses and very high pressure SIS-OPN balloon inflation at 50 atm also failed to expand the lesion. Surprisingly, subsequent inflation of a 3.0 mm Scoreflex expanded the lesion with a nice final result after implantation of an additional DES.

[@user-su4he3ju7t]

Great case, Professor Emmanouil Brilakis! We need some arrows in our algorithm for treating balloon undilatable lesion!) Thank You very much!!! How can we cross this lesion through the subintimal space, if some other methods including in algorithm was failed?

[@nguyenlephuong9489]

Thank you

[@shangz0216]

Thanks for the excellent case presentation.

[@kathorhanes]

Wire looks weird at end, subintimal?

[@farukakturk5388]

Normally IVL allows 80 bursts? So why not rotational atgerectomy according to reference vessel diameter?

[@johnwilson7660]

I wonder what her previous coronary angiograms looked like. What endoflator do you use with the opn balloon? Do you know the reason why the wire gets stuck in the opn balloon? Is it because the pressure from the balloon crushes the shaft of the catheter against the wire? Are there specific wires/coatings that are more likely to get stuck? Have you tried using the opn balloon with a buddy wire next to it? It must have been tempting to treat the lad distal to that stent.

[@augustoboggi4655]

Have you considered the use of Shock-Wave ?

[@ahmettemiz2528]

IVL = shock wave

[@farukakturk5388]

And ı would like to ask tha ATM of scoreflex balloon? By the way again and again thank you very much for that you shared with us!