Successful Percutaneous Coronary Intervention (PCI) of a Heavily Calcified Left Main Artery Using Shockwave Intravascular Lithotripsy and Intra-aortic Balloon Pump (IABP) Support in an Octogenarian Acute Coronary Syndrome Patient Deemed High Risk

Managing heavily calcified left main (LM) disease in elderly patients presenting with acute coronary syndrome (ACS) presents a significant clinical challenge, particularly when surgical revascularization is considered high risk. Intravascular lithotripsy (IVL) has emerged as a promising technique for calcium modification in high-risk coronary interventions. We report the case of an 81-year-old woman with a history of diabetes mellitus, hypertension, stage 4 chronic kidney disease, and chronic obstructive pulmonary disease who presented with anterior acute coronary syndrome. Coronary angiography revealed heavily calcified LM disease with triple vessel involvement. The cardiothoracic surgery team assessed her as high risk for surgical revascularization due to her advanced age and multiple comorbidities. Echocardiography showed regional wall motion abnormalities with moderately reduced ejection fraction (40%), and high-sensitivity troponin I was markedly elevated (>24,000 ng/L). Percutaneous coronary intervention (PCI) was performed with intra-aortic balloon pump (IABP) support. Shockwave IVL was used to prepare the calcified LM lesion, followed by successful stenting with restoration of Thrombolysis in Myocardial Infarction (TIMI) III flow. The patient had an uneventful recovery and was discharged on optimal medical therapy. This case highlights the feasibility and safety of combining IVL and IABP support in treating heavily calcified left main lesions in elderly ACS patients deemed high risk for surgical revascularization. It underscores the importance of individualized decision-making and the role of advanced calcium-modification technologies in high-risk coronary interventions.