True lumen stenting guided by intravascular ultrasound-confirmed wire repositioning from the subintimal space following balloon inflation during intravascular lithotripsy-induced coronary dissection: a case report

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.

An 80-year-old woman with unstable angina underwent percutaneous coronary intervention for a severely calcified and tortuous left anterior descending artery. Intravascular lithotripsy 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. Intravascular ultrasound 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.

Even when a guidewire migrates into the subintimal space during IVL-induced coronary dissection, balloon inflation may dynamically shift the device towards the true lumen due to anchoring by wire segments located proximally and distally within unaffected vessel segments. Real-time IVUS is indispensable for visualizing 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.