Coronary calcification poses a major challenge in interventional cardiology, increasing procedural complexity and leading to worse clinical outcomes due to impaired stent expansion and apposition.1

Intravascular lithotripsy (IVL) has emerged as an effective method for modifying both superficial and deep calcium. The LithiX system (Elixir Medical Corporation, United States) is a new-generation IVL device that uses Hertz contact tension to deliver radial micro-explosions via metallic hemispheres embedded in a semi-compliant balloon. This mechanism creates concentric calcium fractures without requiring an external energy source or complex setup. Unlike ultrasound-based lithotripsy systems, the LithiX balloon offers improved deliverability, a simplified design, and potential use in distal or tortuous vessels. These features may shorten procedure times and expand its applicability to a broader range of patients. Comparative clinical data between Shockwave and LithiX are not yet available. However, initial experiences with LithiX suggest several advantages in selected scenarios, particularly in anatomies where device navigation is difficult. Its lower-profile balloon design may enhance deliverability in distal or tortuous vessels, helping to define a distinct clinical niche for LithiX among calcium modification tools. Initial clinical studies have shown a high degree of technical success and a low rate of immediate adverse events.2,3 A recent national study by Jurado-Román et al. compared calcium modification techniques (rotational atherectomy, Shockwave IVL, and excimer laser coronary atherectomy) in 171 patients with complex calcified lesions. All strategies achieved high procedural success; however, IVL showed the most favorable safety profile, with a lower incidence of complications such as coronary perforation and slow flow. IVL was also associated with shorter procedural times and reduced contrast volume, particularly in patients with impaired left ventricular function or chronic kidney disease.4

We present a series of clinical cases illustrating the initial experience with the LithiX system across multiple interventional cardiology centers in Spain.

The patients in this report were specifically selected because they shared a common feature: severe, angiographically visible calcification expected to compromise stent expansion if treated with balloon angioplasty alone. In several cases, noncompliant balloon predilatation failed, or atherectomy was considered but deferred due to distal location, tortuosity, or risk of complications such as slow flow, perforation, or hemodynamic instability. Patient selection was guided by current indications for intravascular lithotripsy, prioritizing balloon-crossable lesions with extensive or deep calcium on angiography or intravascular imaging, calcified nodules, as recently reviewed by Fernández-Cordón, et al.,5 or failure (or anticipated failure) of high-pressure balloon angioplasty. The decision to use the LithiX IVL system aimed to generate initial real-world clinical experience and systematically assess its feasibility, deliverability, and acute procedural outcomes in this high-risk subset. Collectively, these carefully selected cases highlight the practical applicability and potential clinical value of LithiX IVL in complex, real-world coronary interventions.

All patients presented with severely calcified coronary lesions, including bifurcations, left main disease, and diffuse multivessel involvement (table 1). The LithiX device was employed as a primary plaque modification strategy, either upfront or after failure of conventional lesion preparation. In all cases, the use of the Lithix balloon resulted in effective lesion preparation, as confirmed by angiographic and intracoronary imaging. Optical coherence tomography (OCT) or intravascular ultrasound (IVUS) consistently demonstrated calcium fracture (figure 1), with visible disruption of deep calcific layers, luminal enlargement, and optimized stent expansion. No complications related to the LithiX system- were reported. Stent implantation was successful in all patients, with optimal final angiographic results. The following case summaries emphasize the clinical relevance and therapeutic value of the LithiX IVL system across a range of anatomically complex and high-risk coronary lesions. Table 1 provides a structured summary of the clinical characteristics, anatomical challenges, and procedural strategies involving LithiX for plaque modification. Each case was guided by intravascular imaging (IVUS or OCT), with angiographic and imaging confirmation of calcium fracture and optimal stent expansion. The table also details the specific rationale for LithiX use, whether selected as a first-line strategy in complex calcified anatomy or as a bailout after failure of conventional techniques.

Figure 1.

Intravascular imaging (IVUS and OCT) before and after using the LithiX system across 6 clinical cases. Pre-procedural imaging shows severe calcified plaques. Post-LithiX images consistently demonstrate visible calcium fractures (white arrows), indicating effective plaque modification. IVUS, intravascular ultrasound; MSA, minimal stent area; OCT, optical coherence tomography; RCA, right coronary artery.

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In conclusion, this initial real-world experience with the LithiX IVL system demonstrated feasibility and excellent deliverability in patients with severely calcified coronary lesions, enabling effective lesion preparation and optimal stent expansion without major periprocedural complications. These observations support its potential as an alternative calcium-modification strategy for selected high-risk anatomies. Larger, prospective studies are warranted to confirm these findings and further define the role of this technology within the spectrum of plaque-modification techniques.