A 63 year old male complaining about angina on effort during his mild daily activities. Risk factor included diabetes mellitus, dyslipidemia , smoking and obesity. Physical examination was unremarkable.

The patient presented with symptoms consistent with typical angina and a prior history of non-ST elevation myocardial infarction (NSTEMI) with unsuccessful revascularization. The resting electrocardiogram (ECG) showed no significant abnormalities.

Dominant right coronary artery (RCA) with a heavily calcified, diffusely diseased segment extending from the ostium to the distal portion. The left anterior descending (LAD) and left circumflex (LCx) arteries show irregular but non-significant stenoses



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PCI to RCA : Canulation using guiding catheter AL 0.75/7Fr, heparin was administered. Workhorse wire to distal PL. Initial attempt with a 1.5 × 15 mm balloon failed to cross the distal lesion and subsequently ruptured. Rotational atherectomy was performed using a 1.5 mm burr at 160–180k rpm with three runs and one polishing pass. A 2.0 × 15 mm semi-compliant balloon was then advanced from distal to proximal segments with the assistance of a guide extension catheter.IVUS evaluation demonstrated a 360° circumferential calcium arc and multiple calcium nodules extending from proximal to distal RCA. Lesion preparation was continued using sequential scoring balloon 2.0 mm and NC 2.5 mm, and cutting balloon 3.0 mm at high pressure. A “dogbone” appearance was noted with the cutting balloon at the proximal RCA. An intravascular lithotripsy (IVL) balloon 3.0 mm was then applied to both distal and proximal RCA, delivering a total of 120 pulses (up to 8 atm).Repeat IVUS confirmed adequate calcium modification and optimal lesion preparation. Three overlapping drug-eluting stents (DES) were deployed: 3.0 × 38 mm (distal–mid RCA), 3.5 × 32 mm (mid RCA), and 4.0 × 22 mm (ostial–proximal RCA), followed by sequential post-dilatation up to 4.0 mm. Final IVUS confirmed good stent apposition and expansion, with a minimal stent area of 6.36 mm² at the distal RCA. TIMI 3 flow was achieved. Total contrast volume: 160 mL, Fluoroscopy time: 01:09:34 minutes, DAP: 232 Gy·cm²



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A stepwise multimodality approach combining rotational atherectomy, specialty balloons, and IVL achieved optimal stent expansion in a severely calcified RCA. Intravascular imaging guidance was essential for safe and successful procedural outcome. All target vessels reached optimal stent expansion and TIMI 3 flow without complications.