A 66-year-old male patient, with a history of ventricular fibrillation arrest 16 years ago, who at that time underwent coronary angiography showing normal coronary arteries and as treated medically for clinically suspected variant angina, presented with new-onset chest tightness.
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Coronary angiography demonstrated a heavily calcified, diffuse long disease in the mid to distal RCA. Initial intravascular ultrasound (IVUS) could not be advanced across the lesion due to the severe calcification. Without predilation with a non-compliant balloon, rotational atherectomy (RA) was performed using 1.25 mm and 1.5 mm burrs. Post-RA IVUS revealed circumferential (270°–360°) encircling calcium with some cracks, but lesion preparation was considered suboptimal.Subsequently, intravascular lithotripsy (IVL) was performed with a 3.0 × 12 mm balloon, delivering 12 pulses to the segment that remained resistant to expansion. Follow-up IVUS demonstrated deep calcium fractures and an increase in the minimal lumen area (MLA) from 2.94 mm² to 5.12 mm². Angiography after IVL showed significant improvement in both flow and luminal narrowing.To further optimize the result, additional dilatation with a 3.5 × 15 mm non-compliant balloon was performed, followed by drug-coated balloon angioplasty using a 2.5 × 30 mm balloon. Final IVUS revealed an MLA of 7.5 mm², and angiography confirmed an optimal result with no flow-limiting dissection.

This case demonstrates the feasibility of a stentless percutaneous coronary intervention strategy in a patient with a diffuse, heavily calcified lesion. Careful lesion preparation with rotatripsy guided by IVUS can allow a safe and effective stentless PCI strategy in selected patients. Intravascular imaging–guided rotatripsy followed by drug-coated balloon angioplasty may represent a valuable alternative treatment option in complex calcified coronary artery disease.