Rationale: Up to 20% of percutaneous intervention (PCI) procedures are challenged by severe calcification, lesion calcification increases procedural complexity and time. S-IVL is supposed to be less effective in vessel size greater than or equal to 3.5 mm and lesions with eccentric calcium. S-IVL devices apply localized pulsatile sonic pressure waves that pass through the soft tissue and modify and fracture the underlying calcium. In literature, S-IVL is found to be useful when the calcium is circumferential and superficial as well as deep. It’s efficacy in large vessel diameter and eccentric calcium is questionable.

Findings: Here with present two cases. The first one is a 75-year-old male patient in whom PCI to LAD was done as a first stage procedure. RCA PCI was deferred as it was a calcified vessel proximally, and there was dog boning with a NC balloon distally. There was a concentric ring of deep calcium as imaged on IVUS. Calcium was treated with a IVL balloon and energy pulses delivered over short separate balloon inflations. The procedure was completed with a good angiographic result. The Second patient is a 65-year-old male in whom the angiogram showed LM to LCX lesion. IVUS showed that there was eccentric and superficial calcium. Lesion was then treated with a 3.5mm IVL balloon with energy pulses delivered over short separate balloon inflations. The procedure was completed with a good final angiographic result.

Conclusion: In our cases, we found S-IVL to be useful for large diameters, deep calcium, and eccentric lesions as characterized by IVUS imaging