The LAD and the diagonal branch were dilated with a 2.5-mm regular noncompliant balloon at 14 atm to enable optical coherence tomography (OCT) and assessment of the extent and distribution of the angiographically visible calcium. Of note, the noncompliant balloon expanded incompletely, which emphasised the lesion’s anticipated degree of calcification, as depicted in
figure 1B (arrow). The subsequent OCT run confirmed the prevalence of extensive circular calcium (
fig. 2A). After predilatation, OCT indicated a minimum lumen area of 2.82 mm
2 within the treated segment. Based on those findings, we decided to use intravascular lithoplasty to optimally prepare the calcified lesion for stent implantation. A 3.0-mm balloon (Shockwave Medical, Fremont, California) was used at 4 atm to deliver six pulses. The OCT investigation after lithoplasty demonstrated calcium cracks in the intima and the media of the LAD (minimum lumen area 3.09 mm
2) (
fig. 2B). A 2.25 × 23 mm everolimus-eluting stent was placed in the diagonal branch and a 3.0 × 33 mm everolimus-eluting stent was implanted in the LAD with use of the mini-crush technique. The LAD was then post-dilated using a 3.5-mm noncompliant balloon at 16 atm followed by a final kissing balloon inflation (3.5-mm noncompliant balloon in the LAD and 2.5-mm noncompliant balloon in the diagonal branch). A good final angiographic result was achieved (
fig. 1C). The next OCT demonstrated good expansion and apposition of the stent (minimum luminal area 5.38 mm
2, stent expansion index 0.81)
(fig. 2C–E
). Since there was some malapposition within very proximal/ostial stent segment (21 struts with >300µm)
(arrow,
fig. 2E), a proximal optimisation procedure using a 4.0-mm noncompliant balloon was additionally performed. The patient was discharged home 2 days later. He is in good condition and free of any cardiac symptom 4 months after the procedure.