Background Percutaneous coronary intervention (PCI) for calcified coronary artery remains challenging in the drug‐eluting stent (DES) era. While recent studies reported the efficacy of orbital atherectomy (OA) combined with DES for calcified lesion, the effectiveness of drug‐coated balloon (DCB) following OA has not been fully elucidated. Methods Between June 2018 and June 2021, 135 patients who received PCI for calcified de novo coronary lesions with OA were enrolled and divided into two groups; OA followed by DCB (n = 43) if the target lesion achieved acceptable preparation, or second‐ or third‐generation DESs (n = 92) if the target lesion showed suboptimal preparation between June 2018 and June 2021. All patients underwent PCI with optical coherence tomography (OCT) imaging. The primary endpoint was 1‐year major adverse cardiac event (MACE), that was a composite of cardiac death, nonfatal myocardial infarction, or target lesion revascularization. Results Mean age was 73 years and 82% was male. In OCT analysis, maximum calcium plaque was thicker (median: 1050 µm [interquartile range (IQR): 945–1175 µm] vs. 960 µm [808–1100 µm], p = 0.017), calcification arc tended to larger (median: 265° [IQR: 209–360°] vs. 222° [162–305°], p = 0.058) in patients with DCB than in DES, and the postprocedure minimum lumen area was smaller in DCB compared with minimum stent area in DES (median: 3.83 mm2 [IQR: 3.30–4.52 mm2] vs. 4.86 mm2 [4.05–5.82 mm2], p < 0.001). However, 1 year MACE free rate was not significantly different between 2 groups (90.3% in DCB vs. 96.6% in DES, log‐rank p = 0.136). In the subgroup analysis of 14 patients who underwent follow‐up OCT imaging, late lumen area loss was lower in patients with DCB than DES, despite lower lesion expansion rate in DCB than DES. Conclusions In calcified coronary artery disease, DCB alone strategy (if acceptable lesion preparation was performed with OA) was feasible compared with DES following OA with respect to 1‐year clinical outcomes. Our finding indicated using DCB with OA might be reduce late lumen area loss for severe calcified lesion.

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Purpose: The association between the extent of the wire and device bias as assessed by optical coherence tomography (OCT) in the healthy portion of the vessel and the risk of coronary artery injury after orbital atherectomy (OA) has not been fully elucidated. Thus, purpose of this study is to investigate the association between pre-OA OCT findings and post-OA coronary artery injury by OCT. Methods: We enrolled 148 de novo lesions having calcified lesion required OA (max Ca angle > 90°) in 135 patients who underwent both pre- and post-OA OCT. In pre-OA OCT, OCT catheter contact angle and the presence or absences of guide-wire (GW) contact with the normal vessel intima were assessed. Also, in post-OA OCT, we assessed there was post-OA coronary artery injury (OA injury), defined as disappearance of both of intima and medial wall of normal vessel, or not. Results: OA injury was found in 19 lesions (13%). Pre-PCI OCT catheter contact angle with the normal coronary artery was significantly larger (median 137°; inter quartile range [IQR] 113–169 vs. median 0°; IQR 0–0, P < 0.001) and more GW contact with the normal vessel was found (63% vs. 8%, P < 0.001). Pre-PCI OCT catheter contact angle > 92° and GW contact with the normal vessel intima were associated with post-OA vascular injury (Both: 92% (11/12), Either: 32% (8/25), Neither: 0% (0/111), P < 0.001). Conclusion: Pre-PCI OCT findings, such as catheter contact angle > 92° and guide-wire contact to the normal coronary artery, were associated with post-OA coronary artery injury.