Percutaneous coronary intervention (PCI) of heavily calcified coronary arteries has evolved dramatically over the past decade, driven by a broadening portfolio of plaque modification tools, including speciality balloons, rotational (RA) and orbital atherectomy (OA), intravascular lithotripsy (IVL), and excimer laser coronary atherectomy (ELCA). Despite this technical progress, severely calcified lesions remain one of the most challenging scenarios in modern PCI. In this unfavourable setting, procedural failure is a constant threat, and a single, apparently isolated event can trigger a cascade of interconnected complications that forces the operator into progressively narrower decision-making windows.
In this issue of EuroIntervention Case Reports, Basile and colleagues1 report an instructive and detailed example of such a scenario: a PCI of a heavily calcified mid-left anterior descending (LAD) artery subocclusion that rapidly escalated from device uncrossability to distal perforation, guidewire entrapment and, finally, a second iatrogenic Ellis type III perforation after bailout ELCA. Although laser-assisted retrieval of an entrapped guidewire has been previously described, this case deserves attention because it condenses several of the pitfalls, and their potential solutions, into a single procedure, characterising modern complex PCI.
A 73-year-old male with active oncological disease and minimal effort angina underwent PCI of a previously unwirable, severely calcified mid-LAD subocclusion. After successful crossing with a Gladius EX14 wire, supported by a Caravel microcatheter (both Asahi Intecc), an initial 1.0 mm and 1.5 mm balloon predilatation and a guidewire exchange with a SION Blue ES (Asahi Intecc) were performed. Despite support escalation with a guide extension catheter, no further device – neither an optical coherence tomography catheter nor small balloons – could be advanced across the lesion. At that stage, a distal LAD perforation occurred during further device manipulation and, shortly afterwards, guidewire entrapment was strongly suspected as a microcatheter could not be advanced across the lesion either. After unsuccessful conventional retrieval manoeuvres, the operators performed bailout ELCA with saline injection over a second parallel wire. Laser application released the entrapped wire but was immediately followed by an Ellis type III perforation in the mid-LAD. The vessel was successfully sealed with two overlapping Papyrus covered stents (Biotronik), while the distal perforation was controlled by distal coil embolisation. The patient remained haemodynamically stable, was discharged on day four, and was angina free at six months.
The main strength of this report lies in its richness of procedural details with high educational value. The authors provide a thorough description of the materials used at each step, together with the complete specifications of the ELCA run. The eight supplementary moving images further enhance the didactic value of the manuscript, allowing the reader to follow the procedural sequence and each complication in real time. Equally valuable is the authors’ intellectual honesty: in the absence of intracoronary imaging at the critical stage, they explicitly describe the mechanism of the laser-related perforation as hypothetical rather than definitive and openly acknowledge the limited generalisability of their experience to routine practice.
Turning to limitations, the inability to perform intracoronary imaging after predilatation leaves both the cause of abrupt device uncrossability and the mechanism of the laser-related perforation essentially speculative. A further caveat is the absence of post-stenting intracoronary imaging, a widely recommended step in complex PCI, particularly given the known underexpansion tendency of covered stents. Finally, the clinical framework of the case deserves further reflection. In a patient with metastatic pancreatic adenocarcinoma – and therefore a limited life expectancy – the decision to pursue such a highly complex PCI after a previously failed attempt could have benefited from a more explicit discussion of the Heart Team’s risk-benefit evaluation. Once the decision to proceed was made, a better upfront preparation could have widened the procedural margin: preprocedural coronary computed tomography (CT) angiography to map calcium burden, a 7 Fr guiding catheter and, most importantly, an upfront, more extensive calcium modification strategy. In severely calcified lesions, small balloon predilatation tends to create unpredictable dissections, usually at the calcified/healthy vessel interface, compromising the use of further plaque modification devices, such as rotational or orbital atherectomy, possibly combined with IVL or speciality balloons. Such a strategy might have modified the calcified substrate early enough to allow delivery of the imaging catheter and to interrupt the subsequent complication cascade.
Several practical messages emerge from this case. First, in complex PCI for heavily calcified coronary arteries, complications are never far away, and meticulous preprocedural planning – anticipating both the possible traps and the corresponding bailout strategies – is strongly recommended.23 Calcium mapping with coronary CT, selection of a guide catheter adequate for all foreseeable escalation steps, and the immediate availability of perforation-management tools should all be addressed before entering the catheterisation lab. Second, a conceptual shift in lesion preparation may be needed: in severely calcified anatomies, the first aim of initial plaque modification should be to create the conditions for an imaging catheter to cross the lesion. Intracoronary imaging before, during, and after stenting is the cornerstone of a truly imaging-guided and guideline-adherent procedural strategy. Third, this case illustrates the judicious use of ELCA as a bailout option: despite its likely contribution to the second perforation, laser application ultimately enabled the percutaneous completion of a procedure that would otherwise have required surgical conversion.
The case by Basile et al1 adds weight to a growing body of evidence supporting ELCA as a bailout option for guidewire entrapment. The mechanistic rationale is attractive: unlike rotational or orbital atherectomy and intravascular lithotripsy, ELCA can be delivered over the existing workhorse wire without crossing the lesion,4 making it uniquely suited to scenarios in which every other device has failed. Yet the evidence remains confined to isolated case reports. Comparative trials5 have begun to position plaque modification tools within the contemporary armamentarium and support a standardised approach to severely calcified lesions, combining meticulous preprocedural planning with an upfront extensive calcium modification strategy (e.g., RA or OA, possibly followed by IVL or speciality balloons), rather than small-balloon predilatation. Yet dedicated data on bailout ELCA – covering optimal laser settings, reproducibility across different anatomies, the incidence of laser-related vessel injury and long-term vessel healing – are still lacking. Multicentre registries and prospective comparative studies are needed to move this technique from anecdote- to evidence-based practice.
Conflict of interest statement
The authors declare no conflicts of interest relevant to this editorial.
