Stent-less percutaneous coronary intervention for a severely calcified coronary lesion using combined orbital atherectomy and intravascular lithotripsy followed by drug-coated balloon: case report

Background Percutaneous coronary intervention (PCI) for severely calcified coronary lesions remains technically challenging. Although the combination of atherectomy and intravascular lithotripsy (IVL) has demonstrated favorable outcomes before drug-eluting stent (DES) implantation, it remains unclear whether a stepwise calcium modification strategy using atherectomy followed by IVL can achieve sufficient lesion preparation to enable a stent-less strategy using drug-coated balloon (DCB) angioplasty. Case summary An 83-year-old woman presented with exertional angina despite optimal medical therapy. Coronary angiography revealed severe calcified stenosis in the proximal left anterior descending artery. Pre-procedural optical coherence tomography (OCT) demonstrated thick circumferential calcification, indicating a high risk of inadequate balloon expansion. Orbital atherectomy (OA) was initially performed and achieved partial superficial calcium modification; however, extensive residual calcification remained (post-OA OCT calcium score of 4). Consequently, additional lesion preparation using IVL was performed, delivering 80 pulses via a 2.5-mm IVL balloon, which successfully created multiple calcium fractures and improved vessel compliance. Post-IVL angiography demonstrated residual stenosis <30% with thrombolysis in myocardial infarction grade 3 flow, and fractional flow reserve was 0.92, supporting the decision to avoid DES implantation. Two paclitaxel-coated balloons were subsequently inflated, resulting in an excellent angiographic and OCT outcome without procedural complications. Follow-up coronary angiography and OCT at 17 months demonstrated sustained vessel patency without restenosis, and the patient remained asymptomatic. Conclusion This case demonstrates the feasibility of a stepwise, OCT-guided stent-less PCI strategy using sequential OA, IVL, and DCB angioplasty for a severely calcified coronary lesion. The complementary calcium-modification mechanisms of OA and IVL achieved effective lesion preparation, enabling safe deferral of stent implantation and successful DCB angioplasty. Favorable angiographic, OCT, and clinical outcomes at 17 months suggest that this stepwise approach may represent a promising treatment strategy for carefully selected patients with severely calcified coronary lesions and warrants further evaluation in larger clinical studies.