Coronary Perforation During Excimer Laser Angioplasty in a Patient With Prior Thoracic Radiotherapy

BACKGROUND: Management of heavily calcified coronary lesions remains challenging despite advances in plaque-modifying technologies. Excimer laser coronary angioplasty (ELCA) is an effective adjunctive strategy with a low risk of no-reflow. CASE SUMMARY: A 75-year-old woman with non-ST-segment elevation acute coronary syndrome and severe left ventricular dysfunction, previously treated with thoracic radiotherapy, underwent percutaneous coronary intervention of a calcified left anterior descending artery lesion. Optical coherence tomography revealed an eruptive calcified nodule with thrombus and a concentric stenosis. ELCA was selected to minimize distal embolization; however, the procedure was complicated by multiple coronary perforations requiring covered stent implantation. DISCUSSION: This case suggests that coronary perforation during ELCA may result from the interplay between lesion complexity, procedural factors, and radiation-related vessel wall remodeling.