65 years old gentleman, ex-smoker presented with worsening chest pain and treated for Unstable Angina. He has Hypertension & Dyslipidaemia and had previous coronary angioplasty to LAD and RCA in 2008. 

Echocardiogram showed 40% with regional wall motion abnormalities. Technetium nuclear imaging showed abnormal perfusion study with stress induced ischaemia detected at mid right coronary artery.

Coronary angiogram showed mild left main stem disease with moderate ISR proximal LAD stent (QFR 0.90) with mild disease at proximal LCx and severe calcification stenosis at mid RCA distal to RCA stent (QFR 0.77). IVUS study showed circumferential calcification.

Using JR3.5/7Fr guiding catheter, we crossed the mid RCA lesion with run through floppy workhorse wire. Intravascular lithotripsy Shockwave (IVL) 3.0/12mm was delivered for 8 cycles before further predilate the lesion with SCOREFLEX 3.0/15mm up to 20atm followed by SCOREFLEX3.5/15mm up to 20atm.  After adequate lesion preparation, we stented the lesion with DES CRE8 EVO 3.5/26 mm and post dilate with ACCUFORCE 4.0/12mm up to 18atm. 
Final IVUS study showed a well opposed stent with no dissection. Repeated QFR post PCI was 0.97. 

Patient was discharged home well the next day and remained well during his follow-up. Intravascular lithotripsy (IVL) is a novel approach to lesion preparation of severely calcified plaques in coronary vessels. It is relatively simple to perform and safely modify calcium while significantly reducing the risk of complications to make procedures more predictable and efficient.