SOLACI | Latin American Society of Interventional Cardiology

Coronary calcification hinders both stent transfer and implantation, and has been associated with a higher risk of complications. Coronary perforation is the worst of them.

Registro CRUNCH: una opción para los stents subexpandidos

In turn, these calcifications affect the preparation of coronary plaque, resulting in an underexpanded stent (US), which is a strong predictor of restenosis and early thrombosis.

For the management of US we have a limited therapeutic arsenal, that includes prolonged dilation with non-compliant balloons at high pressure, off-label rotational/orbital atherectomy, and the use of excimer laser (unavailable in many places).

Lately, intravascular lithotripsy (IVL) has been proposed as an alternative to treat US, with a low level of evidence because only case reports are available, unlike what happens with its use in native calcified lesions (DISRUPT-CAD).

Based on this concern, the CRUNCH registry was used to assess the safety and efficacy of IVL for the treatment of US caused by coronary calcification.

This is an international multicenter registry that included 70 patients, average age 73 years, 52% of them with ACS, who underwent IVL therapy for previously implanted stents (from 30 days to over 5 years after implantation), or as bailout therapy after a recent angioplasty (41% of cases).

Quantification was performed by quantitative coronary analysis (QCA), intravascular ultrasound (IVUS) and optical coherence tomography (OCT) —at operator’s discretion—, and reference values were taken for vessel area, minimal luminal area, and minimal stent area. The efficacy outcomes assessed were a composite of technical success and percent diameter stenosis ≤50% (DS %), and safety outcomes (major adverse cardiac events [MACE]).

The DS % showed a relative difference of 57% (p < 0.001), with a 49-% minimum luminal diameter difference measured by QCA (p < 0.001) and a 60.7-% gain in minimum luminal area (IVUS) after IVL (p < 0.001). The mean hospitalization was two days, with no reported MACE. The multivariate analysis showed that IVL as bailout and ostial location of the US had a negative impact on luminal diameter gain.

Conclusions

The IVL system had a high rate of technical success, with significant gains in the luminal and stent areas, and two suboptimal scenarios: as bailout therapy and in case of ostial location. Furthermore, there were no procedure-related complications nor MACE events.

While this is a registry, its data is promising for IVL treatment. A larger number of patients and randomized studies are still needed before adopting this therapy as a validated tool for the treatment of US.

Dr. Omar Tupayachi.
Member of the Editorial Board, SOLACI.org

Original Title: Coronary lithotripsy for the treatment of underexpanded stents the international multicentre CRUNCH registry.

Reference: Tovar Forero, M. N., Sardella, G., Salvi, N., Cortese, B., di Palma, G., Werner, N., Aksoy, A., Escaned, J., Salazar, C. H., Gonzalo, N., Ugo, F., Cavallino, C., Sheth, T. N., Kardys, I., Van Mieghem, N. M., & Daemen, J. (2022). Coronary lithotripsy for the treatment of underexpanded stents; the international multicentre CRUNCH registry. EuroIntervention: Journal of EuroPCR in Collaboration with the Working Group on Interventional Cardiology of the European Society of Cardiology. https://doi.org/10.4244/EIJ-D-21-00545.