Contemporary tools and devices for coronary calcium modification

Abstract

With the aging population, up to a third of patients referred for percutaneous coronary intervention (PCI) have moderate or severe calcified lesions assessed by coronary angiography. The presence of coronary calcium is associated with difficult device delivery, sub-optimal stent deployment, and prolonged procedures, with more complications. Furthermore, it is known that sub-optimal stent expansion is associated with poor clinical outcomes. In this manuscript we describe how to quantify the severity of coronary calcium, review the armamentarium of contemporary devices available for calcium modification, and provide a systematic approach to device selection, assessment of successful calcium modification, and stent optimization.

Coronary Intravascular Lithotripsy Effectiveness and Safety in a Real-World Cohort

“…Despite their relevance, other calcium-modifying techniques have several limitations [1,4]. Conventional balloons, semi-compliant or NC, are often effective in modifying coronary calcified plaques, and pre-dilating lesions with these balloons frequently prepares the lesion and allows stent implantation with an appropriate minimal stent area [17,18]. However, high-pressure balloon dilatation may expand preferentially to the non-calcified segments of the vessel, delivering insufficient force to induce calcium fracture [1,5].…”

“…Moreover, these balloons often lead to dissections between the calcified and the healthy segments [1]. High-pressure dual-layer NC balloons such as the OPN balloon have provided a low-profile device which can exert very high pressure on the lesion with increased uniformity, with an increased risk of coronary dissection or perforation [17,18]. Cutting balloons have microsurgical blades bonded longitudinally along their surface, creating shallow incisions in the calcified atherosclerotic plaque.…”

“…This exposes the more elastic intimal tissue, allowing for greater vessel compliance and improved stent expansion. These balloons are bulky and present a worse profile to cross the lesion [17,18]. Scoring balloons are semi-compliant balloons with three to four rectangular nitinol-based struts that encircle the balloon in a helical pattern in an attempt to reduce the mechanical trauma on the vessel and present a higher crossing profile [17,18].…”

“…These balloons are bulky and present a worse profile to cross the lesion [17,18]. Scoring balloons are semi-compliant balloons with three to four rectangular nitinol-based struts that encircle the balloon in a helical pattern in an attempt to reduce the mechanical trauma on the vessel and present a higher crossing profile [17,18]. Rotational atherectomy uses a diamondencrusted elliptical burr over a specialized 0.009-inch guidewire and abrades non-elastic, fibro-calcified tissue into small particles while deflecting off softer elastic tissue.…”

Contemporary Management of Severely Calcified Coronary Lesions

“…The periprocedural assessment of the extent and thickness of coronary calcium is critical for calcium modification planning [ 7 , 8 ]. There are many technologies available to modify severely calcified plaques, such as non-compliant (NC) balloons, rotational, orbital and laser atherectomy, and intravascular lithotripsy (IVL) [ 9 ]. Each of these modalities of calcium modification has advantages and disadvantages.…”