We highlight a case of severe LMS & ostial CX ISR associated with heavily calcification, treated satisfactory with IVL. 52-year-old lady presented with triple-vessel CAD diagnosis in July 2022. She was declared unsuitable for CABG due to substantial co-morbidities. PCI was performed to her LMS, LAD, and CX. In February 2023, She was readmitted with STEMI. Angiogram confirmed thrombotic occlusion of the LMS extending into the CX. Her LMS and LAD disease were addressed by cutting balloon angioplasty and high-pressure dilatation. The CX artery was treated with drug-eluting stent placement and post-dilation using a NC balloon. The ostial CX stent appeared partially expanded. It was decided to accept the angiographic result and reassess her CX disease later. 4 weeks later, angiogram was performed which showed her proximal LAD accelerated stenosis and ostial CX stent recoiling. The LAD was managed with cutting balloon angioplasty and NC balloon dilatation, followed by drug-eluting balloon angioplasty. CX was addressed by IVL balloon of 3.5 x 12mm.Three cycles of ten pulses were delivered at nominal pressures. The ostial CX was subsequently treated with a drug eluting balloon, followed by a kissing balloon inflation in the LAD and CX. The circumflex ostium displayed significant improvement and proper expansion. Patient was discharged home on DAPT next day. Evidence for IVL in ISR is still limited compared to de-novo disease. The decision to use IVL should be based on the assessment of the coronary artery anatomy, degree of calcification, and the clinical judgment of the interventional cardiologist.

Muhammad Muneeb Arshad MRCP ( London) is working in University hospitals Birmingham NHS Foundation Trust as Registrar. He has special interest in interventional cardiology.