Lipid-Rich Plaque Beneath Dense Calcium: Imaging-Guided Lithotripsy in Calcified Double-Vessel Disease.

BACKGROUND

Grayscale intravascular ultrasound grades coronary calcium but cannot detect lipid sequestered behind a calcific plate because both attenuate the ultrasound signal.

CASE SUMMARY: A 56-year-old man with palpitations and exertional chest discomfort had double-vessel disease: a critical proximal left anterior descending (LAD) stenosis and a severe mid-to-distal right coronary artery (RCA) lesion. Coregistered near-infrared spectroscopy and intravascular ultrasound showed near-circumferential calcium in both vessels, with a large lipid core hidden beneath the LAD calcific shell (maximum lipid core burden index over 4 mm: 788) and a lipid-poor RCA focus (maximum lipid core burden index over 4 mm: 249). Lithotripsy and drug-eluting stents were used in both vessels. The lipid-rich LAD expanded well; the lipid-poor RCA focus did not.

TAKE-HOME MESSAGE: Plaque chemistry, not calcium geometry alone, may explain why some calcified segments resist lithotripsy.