Managing Dialysis-Associated Haemodynamic Instability in Critical Calcific Left Main Stem Disease With Tachycardia-Bradycardia Syndrome Using Intravascular Lithotripsy-Assisted Percutaneous Coronary Intervention and Permanent Pacemaker Implantation

Patients with end-stage renal disease experience an accelerated form of systemic vascular calcification involving both intimal atherosclerosis and medial calcific sclerosis (Mönckeberg's sclerosis). This dual pathology creates unique challenges for coronary revascularisation. We present a dialysis-dependent woman with severe calcific critical left main stem bifurcation disease who underwent successful intravascular lithotripsy-assisted, optical coherence tomography-guided percutaneous coronary angioplasty. She had concomitant severe bradycardia from sinoatrial node dysfunction with paroxysmal atrial fibrillation, which resolved with implantation of a pacemaker. This case highlights the pathobiology underpinning dysmorphic vascular calcification in end-stage renal disease, its impact upon the complex cardiac presentation, and the need for a specialised device-based strategy to achieve a favourable outcome.