Dual-Technique Approach Improves Stent Expansion in Calcified Coronary Lesions

Inadequate expansion is associated with restenosis, blood clots, and repeat procedures. New findings now show that combining two calcium-modification techniques can improve stent expansion in patients with these challenging lesions.

Researchers at The Mount Sinai Hospital (New York, NY, USA) evaluated a treatment approach that combines rotational atherectomy with intravascular lithotripsy before coronary stent placement. The strategy, described as the “Shave and Shake” concept, uses rotational atherectomy to modify protruding calcium. It then applies intravascular lithotripsy through a specialized balloon to deliver shockwave pulses that fracture deeper calcium and improve vessel flexibility.

The NODULE-SHOCK randomized clinical trial enrolled 120 patients with severely calcified coronary arteries. Among 66 patients with calcified nodules, 33 received rotational atherectomy plus intravascular lithotripsy, while 33 received intravascular lithotripsy alone. Researchers used optical coherence tomography to characterize the nodules before treatment, assess response to calcium modification, and measure final stent expansion.

The combined treatment produced an approximately 19% greater stent area than intravascular lithotripsy alone. Final stent area averaged 7.41 mm² with rotational atherectomy plus intravascular lithotripsy compared with 6.23 mm² with intravascular lithotripsy alone. Stents in the combined-treatment group were also more circular and symmetric, and procedural success was 100% compared with 97% in the intravascular lithotripsy-only group.

The trial also assessed 54 patients with severely calcified lesions without calcified nodules. In this cohort, 27 patients received a maximum-pulse intravascular lithotripsy strategy of up to 120 pulses, while 27 received physician-selected dosing of approximately 75 to 80 pulses. Extra pulses did not improve expansion, with final stent area measuring 5.50 mm² versus 5.56 mm².

Across both cohorts, investigators reported no deaths, heart attacks, repeat procedures involving the treated artery, or stent thromboses during the first 30 days. The findings were presented at the Transcatheter Cardiovascular Therapeutics conference in San Diego and published in JACC: Cardiovascular Interventions on November 1, 2026. One-year follow-up is ongoing, and larger multicenter randomized trials are needed to determine whether improved stent expansion leads to better long-term clinical outcomes.

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