True lumen stenting guided by IVUS-confirmed wire repositioning from the subintimal space following balloon inflation during IVL-induced coronary dissection: a case report
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2026
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Abstract
Abstract Background Intravascular lithotripsy (IVL) is an effective modality for modifying severely calcified coronary lesions; however, IVL-induced coronary dissection may occasionally lead to inadvertent guidewire migration into the subintimal space. In such complex scenarios, real-time intravascular ultrasound (IVUS) is essential for identifying wire position, understanding dynamic wire–vessel interactions, and guiding safe stent deployment. Case Summary An 80-year-old woman with unstable angina underwent percutaneous coronary intervention for a severely calcified and tortuous left anterior descending artery. IVL was performed for calcium modification, but a longitudinal medial dissection flap developed, and the guidewire migrated into the subintimal space due to tortuosity-related wire bias. Multiple rewiring attempts using a double-lumen catheter and balloon support were unsuccessful. Real-time IVUS was used to evaluate the behaviour of a semi-compliant balloon positioned on the subintimal wire. IVUS demonstrated that balloon inflation redirected both the balloon and wire from the subintimal space into the true lumen, facilitated by anchoring of proximal and distal wire segments that remained within the true lumen. This confirmation enabled safe and accurate deployment of a drug-eluting stent in the true lumen. Discussion Even when a guidewire migrates into the subintimal space during IVL-induced coronary dissection, balloon inflation may dynamically shift the device toward the true lumen due to anchoring by wire segments located proximally and distally within unaffected vessel segments. Real-time IVUS is indispensable for visualising this dynamic behaviour and confirming whether balloon or stent expansion occurs within the true lumen. This IVUS-guided strategy may be valuable when conventional rewiring techniques fail.
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| Authors | Hideo Tokuyama |
| Journal | European Heart Journal - Case Reports |
| Year | 2026 |
| DOI |
10.1093/ehjcr/ytag433
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| URL | |
| Keywords | Keywords not found |
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