Complex Percutaneous Intervention and Intravascular Lithotripsy for Critical Cabrol Anastomotic Stenosis Jeopardizing Global Coronary Circulation

BACKGROUND: Late coronary anastomotic complications after Cabrol composite graft repair for aortic dissection are rare and pose unique revascularization challenges. CASE SUMMARY: A 72-year-old man with a prior Cabrol composite mechanical aortic graft presented with progressive exertional angina and dyspnea. Stress imaging showed extensive ischemia. Coronary angiography revealed occlusion of the right Cabrol limb and a severely calcified stenosis at the left coronary anastomosis, jeopardizing global coronary supply. After multidisciplinary planning, high-risk percutaneous coronary intervention was undertaken with standby extracorporeal membrane oxygenation support. Conventional balloon techniques failed to sufficiently modify the lesion. Intravascular ultrasound demonstrated dense circumferential calcification at the anastomotic site. Intravascular lithotripsy enabled partial lesion preparation, permitting successful drug-eluting stent deployment. DISCUSSION: This case highlights multiple unique interventional challenges in a single-remaining-vessel situation with limited hemodynamic support options. TAKE-HOME MESSAGE: Intravascular imaging and lithotripsy enabled successful high-risk percutaneous coronary intervention of a heavily calcified Cabrol graft.