Drug-Coated Balloon Performance in a Calcified Coronary Bifurcation Complicated by Cardiogenic Shock

Abstract

Background

Complex coronary disease in frail patients requires balancing procedural efficacy, safety, and permanent metallic implantation.

Case Summary

A 76-year-old frail woman presented with non–ST-segment elevation acute coronary syndrome and triple-vessel disease, including a calcified left anterior descending artery-diagonal bifurcation, circumflex culprit lesion, and right coronary artery chronic total occlusion. After circumflex stenting, the bifurcation lesion underwent extensive preparation with balloons and intravascular lithotripsy. The procedure was complicated by acute diagonal occlusion with hemodynamic instability. Flow was restored using drug-coated balloons (DCBs) in both branches, avoiding complex stenting. At a staged procedure, the right coronary artery chronic total occlusion was recanalized with a hybrid DCB and focal stent strategy. Repeat angiography demonstrated positive remodeling.

Discussion

This case illustrates a scaffold-minimizing hybrid strategy for complex calcified coronary disease.

Take-Home Messages

DCBs may be effective in selected high-risk patients. In selected cases, acute flow compromise during complex percutaneous coronary intervention can be managed with DCB angioplasty without resorting to bailout stenting.

Visual Summary

Visual Summary.

Hybrid Revascularization Strategy in a Frail Elderly Patient With Complex Multivessel Coronary Artery Disease

The index LAD/D1 intervention, staged RCA CTO PCI, and favorable 1-year angiographic and clinical outcomes. CTO = chronic total occlusion; DCB = drug-coated balloon; DES = drug-eluting stent; IVL = intravascular lithotripsy; LAD = left anterior descending artery; LVEF = left ventricular ejection fraction; MI = myocardial infarction; NSTEMI = non–ST-segment elevation myocardial infarction; PCI = percutaneous coronary intervention; RCA = right coronary artery.

History of Presentation

A 76-year-old woman presented in the emergency department with retrosternal chest pain lasting for the past 3 hours. The blood pressure was 120/70 mm Hg, and the heart rate was 70 beats/min. Electrocardiography showed sinus rhythm with pathologic Q waves and negative T waves in the inferior and anterolateral leads. High-sensitivity troponin increased dynamically (600-1,800). Transthoracic echocardiography showed a nondilated left ventricle with extensive regional wall-motion abnormalities involving the mid-apical and inferior interventricular septum, apex, and lateral wall, and moderately reduced left ventricular systolic function, with an ejection fraction of 30% to 35%. Of note, 2 years before admission, coronary computed tomography angiography had documented severe calcific disease of the mid-proximal left anterior descending artery (LAD) together with severe right coronary artery (RCA) disease, but the patient refused further investigations. Also, at that time, no wall-motion abnormalities were described and ejection fraction was preserved, despite symptoms of heart failure.

Take-Home Messages

• •Drug-coated balloon strategies are feasible in selected complex coronary lesions.
• •Drug-coated balloon may avoid bailout stenting in selected cases of acute flow compromise.

Past Medical History

The patient’s past medical history included hypertension, diabetes mellitus, dyslipidemia, chronic coronary syndrome, mild mitral regurgitation, and heart failure with preserved ejection fraction.

Differential Diagnosis

The differential diagnosis included ST-segment elevation myocardial infarction, unstable angina, and acute aortic syndrome, which were excluded based on the patient’s symptoms and electrocardiographic and imaging results.

Management

Index procedure

The coronary angiography revealed a severe three-vessel disease (Figure 1, Videos 1 to 3). The circumflex artery, considered the culprit, was treated with a 3.0 × 22-mm drug-eluting stent implantation after optimal predilatation, achieving an optimal result. Attention was then directed to the severely calcified LAD-first diagonal bifurcation. The LAD and diagonal branch were wired with BMW (Abbott Vascular) and Runthrough Intermediate (Terumo) 0.014-inch guidewires. Lesion preparation was performed sequentially with a 2.5 × 20-mm semicompliant balloon, 2.5 × 12-mm and 3.25 × 15-mm noncompliant balloons, and 2.5 × 10-mm and 3.0 × 10-mm cutting balloons. Persistent balloon underexpansion and a marked dog-boning effect suggested severe calcium burden (Figure 2, Video 4). Calcium modification was therefore performed with a 3.5 × 12-mm intravascular lithotripsy (IVL) balloon using 8 cycles of 10 pulses, achieving improved balloon expansion (Figure 3, Video 4).

Figure 1.

Baseline Coronary Angiography

(A) Angiographic view of the right coronary artery showing a chronic total occlusion of the mid–right coronary artery. (B) Angiographic view of the left coronary artery showing a severe stenosis of the mid–left circumflex artery and a calcified subocclusive lesion of the mid–left anterior descending artery. (C) Selective cranial angiographic view of the left coronary artery highlighting severe calcification at the left anterior descending artery-first diagonal bifurcation.

Figure 2.

Magnified Angiographic View Demonstrating the Dog-Boning Effect in a Heavily Calcified Mid–Left Anterior Descending Artery Lesion Resistant to Standard Balloon Dilation

Figure 3.

Intravascular Lithotripsy Balloon Optimal Expansion After 8 Cycles of 10 Pulses

Immediately after lithotripsy, the procedure was complicated by severe chest pain, ischemic electrocardiographic changes, and hemodynamic collapse, with blood pressure decreasing to 70/50 mm Hg. Control angiography showed slow flow in the main diagonal branch arising from the stenotic segment and no flow in 1 diagonal branch (Figure 4, Video 5). At this point, the procedural priority shifted from lesion optimization to rapid restoration of coronary flow and hemodynamic stabilization.

Figure 4.

Angiographic View Showing No-Flow in the Diagonal Branch After Intravascular Lithotripsy of the Mid–Left Anterior Descending Artery Lesion

The diagonal branch was rewired and dilated with a 2.5 × 20-mm semicompliant balloon. To avoid complex 2-stent bifurcation percutaneous coronary intervention (PCI) in an unstable patient, a drug-coated balloon (DCB)–based bailout strategy was adopted. DCB angioplasty was performed in the LAD with a 3.0 × 30-mm DCB and in the diagonal branch with a 2.5 × 20-mm DCB, using prolonged inflations of 60 to 70 seconds at 8 to 12 atm. Final angiography showed restoration of TIMI flow grade 3, rapid hemodynamic recovery, and <30% residual stenosis in both branches (Figure 5, Video 6). The patient had an uneventful recovery and was discharged on dual antiplatelet therapy and guideline-directed medical therapy.

Figure 5.

DCB Inflation and Final Index Result

(A) Diagonal branch paclitaxel balloon inflation. (B) Left anterior descending artery paclitaxel balloon inflation. (C) Final angiographic result showing <30% residual stenosis in both branches.

Staged procedure: RCA CTO PCI

Two months later, staged recanalization of the RCA chronic total occlusion (CTO) was performed. Control angiography showed a short, unobstructed left main coronary artery, a markedly improved LAD-first diagonal bifurcation without residual restenosis, and a patent circumflex stent without de novo lesions. The RCA showed severe ostial stenosis followed by a chronic total occlusion in the midsegment, with distal filling through collaterals from the circumflex artery.

The RCA CTO was approached using a 6-F JR 4.0 guiding catheter positioned in the RCA ostium. Initial crossing attempts with a polymer-jacketed guidewire, including balloon support, were unsuccessful. The occlusion was subsequently crossed with a dedicated CTO guidewire advanced distally into the RCA. Sequential predilatation was performed with 1.0 × 15-mm, 1.2 × 12-mm, and 2.0 × 15-mm semicompliant balloons at 16 to 18 atm, followed by a 3.0 × 8-mm noncompliant balloon at 18 atm along the mid-RCA segment. DCB angioplasty was then performed with a 3.0 × 30-mm DCB using a prolonged 90-second inflation at 12 atm.

Because of significant ostial recoil, the ostial RCA lesion was further predilated with a 3.0 × 15-mm cutting balloon at 16 atm. As recoil persisted, a 3.5 × 15-mm drug-eluting stent was implanted at 14 atm. Final angiography showed an excellent result with TIMI flow grade 3 and no residual stenosis (Figure 6, Video 7). During this procedure, control angiography of the left coronary system showed important lumen gain consistent with positive remodeling in the LAD-diagonal bifurcation (Figure 7, Video 8).

Figure 6.

Final Result of the Right Coronary Artery Chronic Total Occlusion Recanalization

(A) Drug-coated balloon inflation in the chronic total occlusion body. (B) Drug-eluting stent implantation in the ostium. (C) Final angiographic result.

Figure 7.

Two-Month Follow-Up

Important positive remodeling and lumen gain.

Outcome and Follow-Up

At 1-year follow-up, coronary angiography confirmed sustained patency of all treated vessels (Figure 8). The LAD-diagonal bifurcation demonstrated late luminal enlargement consistent with positive remodeling. Left ventricular ejection fraction improved to 40% to 45%, and the patient remained asymptomatic without major adverse cardiovascular events.

Figure 8.

One-Year Follow-Up Angiographic Result

One-year angiographic follow-up showing sustained patency of left anterior descending artery-diagonal (A), circumflex (B), and right coronary artery (C).

Discussion

This case illustrates the challenges of revascularization in frail patients with complex coronary disease, who commonly present with multivessel involvement, anatomically complex lesions, and a clinical profile in which frailty and competing risks substantially influence the balance between surgical and percutaneous treatment strategies.¹ Among the anatomical features that most strongly determine PCI complexity, severe coronary calcification is especially important because it reduces device deliverability, limits balloon expansion, predisposes to stent underexpansion, and is associated with worse procedural and long-term outcomes.²

This was exactly the most important technical challenge in our case as well, with clear mechanical resistance to conventional balloon expansion, evidenced by marked dog-boning despite escalation from semicompliant to noncompliant, and cutting balloons. This pattern is clinically important because inadequate lesion compliance is one of the strongest predictors of suboptimal PCI in calcified disease and failure to modify calcium early tends to propagate downstream problems rather than solve them.³ Comparative contemporary data suggest that IVL is a safe and effective calcium-modification strategy in severe coronary calcification and may compare favorably with rotational atherectomy in selected lesions, including bifurcations or CTO.^4,5 For this reason and because we wanted to minimize the risk of slow-flow associated with a potential atherectomy, we performed IVL. However, the procedure was complicated by sudden no-flow in a major diagonal branch, necessitating immediate revision of strategy to restore hemodynamic stability without resorting to complex 2-stent bifurcation reconstruction. Reopening the side branch followed by DCB angioplasty aligns with emerging evidence supporting DCB use in compromised side branches during provisional strategies, with improved 1-year outcomes compared with conventional balloon angioplasty.⁶ More broadly, hybrid DCB strategies for coronary bifurcation lesions have been associated with lower composite adverse-event rates than both 2-stent and provisional-stenting approaches, supporting their use in selected cases where side-branch preservation is required but additional metallic implantation is undesirable.^7,8 Because DCBs have been shown to reduce major bleedings while offering similar benefits as DES in selected complex lesions subsets⁷ and their use after IVL was safe in small cohorts,⁹ we decided to perform a DCB strategy for the LAD as well, with an acceptable result.

The CTO component of this case is also relevant, because long calcified CTOs are among the lesion subsets in which operators are most tempted to implant long stented segments, even though extensive metal burden may be particularly problematic in negatively remodeled or diffusely diseased vessels. Emerging evidence indicates that DCB-based or hybrid DCB-plus-DES treatment in CTO PCI may reduce total stent burden without an apparent compromise in medium-term clinical outcomes. The staged management of the RCA CTO further illustrates a hybrid strategy, combining DCB angioplasty with selective stenting only where necessary. Such an approach may reduce total stent burden, particularly in long or diffusely diseased segments.⁸

A notable finding was the late luminal enlargement observed in the LAD-diagonal bifurcation at follow-up. This supports the concept of positive vessel remodeling after DCB angioplasty, a phenomenon increasingly recognized in scaffold-free coronary intervention.¹⁰ Therefore, this case provides angiographic evidence of positive remodeling following IVL-facilitated DCB treatment in a true bifurcation lesion. Although this phenomenon should be interpreted cautiously in a single-patient report, it is biologically plausible and has been described after successful DCB angioplasty in de novo coronary lesions.

A limitation of this case is the absence of intravascular imaging, which was not performed due to procedural complexity and hemodynamic instability; however, the lesion appeared focal and exhibited a high calcific burden on angiography, allowing adequate assessment and guiding lesion preparation, although imaging could have provided additional insight into calcium modification and vessel response.

Overall, the case supports a pragmatic interpretation of the “leave-nothing-behind” concept, emphasizing minimal necessary scaffolding rather than complete avoidance of stents.

Conclusions

In frail patients with complex coronary anatomy, a staged hybrid strategy combining IVL, DCBs, and limited stenting may provide effective revascularization while minimizing permanent metallic implantation. Procedural success depends on both adequate lesion preparation and the ability to adapt strategy in response to intraprocedural complications.

Funding Support and Author Disclosures

The authors have reported that they have no relationships relevant to the contents of this paper to disclose.

Appendix

Video 1

Diagnostic CA—RCA CTO

Video 2

Diagnostic CA—Culprit LCx Lesion

Video 3

Diagnostic CA—LAD-D1 Bifurcation Lesion

Video 4

Dog-Boning Effect During Predilation of LAD-D1 Lesion

Video 5

Slow Flow in D1 After LAD IVL

Video 6

LAD Final Angiographical Result

Video 7

RCA CTO PCI With a Blended DES-DCB Strategy

Video 8

Two-Month Follow-Up of the LAD-D1 Lesion, With Evidence of Positive Remodeling