Abstract
Background: Severe coronary artery calcification (SCAC) remains one of the most challenging lesion subsets in percutaneous coronary intervention (PCI), affecting approximately 20–30% of patients undergoing coronary revascularization. SCAC is associated with an increased risk of stent underexpansion, stent thrombosis, and in-stent restenosis. Various calcium-modification techniques have been developed, including rotational/orbital atherectomy (RA/OA), intravascular lithotripsy (IVL), and cutting/scoring balloons. More recently, the combined RA + IVL strategy has gained recognition following the publication of the DUAL-PREP trial (2025). Case Presentation: A 78-year-old man with a history of hypertension, diabetes mellitus, previous myocardial infarction treated with left anterior descending artery (LAD) stenting in 2016, and heart failure with a left ventricular ejection fraction of 45% presented with exertional angina. Coronary angiography revealed a severely calcified 95% stenosis in the proximal-to-mid right coronary artery (RCA), characterized by marked vessel tortuosity, circumferential 360° calcium, and the presence of calcific nodules. PCI was successfully performed using a combined lesion-preparation strategy consisting of rotational atherectomy (RotaPro) followed by intravascular lithotripsy with a 3.0 × 15 mm IVL balloon under continuous intravascular ultrasound (IVUS) guidance. The final result demonstrated optimal stent expansion, symmetric stent geometry, and complete stent apposition. Discussion: This case illustrates a stepwise RA-to-IVL strategy based on the updated 2025 device-selection algorithm for heavily calcified coronary lesions. Rotational atherectomy effectively modifies superficial calcium and facilitates device delivery, whereas IVL further fractures deep calcium deposits and residual calcific nodules. The DUAL-PREP study (118 patients from 20 centers in Japan) confirmed the safety and efficacy of this combined approach, reporting a 30-day major adverse cardiovascular event (MACE) rate of 1.7% and a procedural success rate of 98.3%. These findings have contributed to a shift in clinical recommendations from a “relative contraindication” to a “conditional recommendation” for IVL use following RA when the residual calcium burden remains significant (OCT calcium score ≥ 3).
