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Review
. 2024 Mar;20(1):1-17.
doi: 10.5114/aic.2024.136415. Epub 2024 Mar 15.

Coronary calcifications, the Achilles heel in coronary interventions

Moustafa Dawood  1 , Moustafa Elwany  1 , Hoda Abdelgawad  1   2 , Mohamed Sanhoury  1 , Moataz Zaki  3 , Eman Elsharkawy  1 , Moustafa Nawar  1
Affiliations
Review

Coronary calcifications, the Achilles heel in coronary interventions

Moustafa Dawood et al. Postepy Kardiol Interwencyjnej. 2024 Mar.

Abstract

Percutaneous coronary intervention in severely calcified coronaries has been associated with higher rates of procedural complications, including myocardial infarction and death in addition to increased frequency of coronary revascularization on an intermediate and long-term basis. The SYNTAX score, which is designed to assess the complexity of coronary artery disease and aids in choosing a revascularization method, allocates two points per lesion when there is heavy calcification present on fluoroscopy. With the advent of novel multimodality imaging technologies, the detection and evaluation of coronary calcifications improved significantly over the last decade. Several tools are now available for modifying calcified lesions including different types of dedicated balloons and atherectomy devices, which may create some degree of confusion regarding the suitable application of each instrument. The aim of this review is to cover this vital topic from different aspects. First, we tried to provide an overview on the pathophysiology and types of coronary calcification and its risk factors. Then, we outlined the available imaging modalities for the evaluation of calcified coronary lesions, highlighting the points of strength and weakness of each of them. A comprehensive discussion of calcium-modifying techniques was elaborated, summarizing their mechanism of action, pros and cons, and possible complications. Finally, an integrated algorithm was proposed for the best management of calcified coronary lesions.

Keywords: coronary calcification; cutting balloon; excimer laser coronary atherectomy; intravascular lithotripsy; rotational and orbital atherectomy; scoring balloon.

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Conflict of interest statement

The authors declare no conflict of interest.

Figures

Figure 1
Figure 1
Imaging of two overlapping LAD stents by different imaging modalities: A – CT angiography showing patent stents, B – flouroscopy showing two LAD stents with some degree of calcification, C – IVUS image showing superficial calcifications and non-obstructive plaque ISR: however, the stent stratus is not visualized clearly, D – OCT image showing two distinct overlapping stent strata with neoatherosclerosis and calcifications. The plaque morphology can be easily inspected due to high resolution of the OCT image
Figure 2
Figure 2
Different types of calcium-modifying balloons: A – OPN NC super high-pressure balloon (OPN NC, SIS Medical AG, Winterthur, Switzerland), B – WOLVERINE Coronary Cutting Balloon (Boston Scientific, Massachusetts, USA), C – Scoreflex Scoring balloon (OrbusNeich, Hong Kong, China), D – Chocolate™* PTA balloon (Medtronic, Minnesota, USA). Reproduced with permission from each company
Figure 3
Figure 3
Different types of atherectomy devices: A – ROTAPRO Atherectomy System burr (Boston Scientific, Massachusetts, USA), B – Diamondback 360™ Orbital Atherectomy System (Abbot, Illinois, USA), Classic Crown mounted concentrically (thick single arrow) and the newer edition MicroCrown mounted eccentrically (two smaller arrows), C – HawkOne™ Directional Atherectomy System (Medtronic, Minnesota, USA), D – CVX-300 Excimer laser system (Philips, Amsterdam, Netherlands). Reproduced with permission from each company
Figure 4
Figure 4
Algorithm for management of calcified coronary lesions
See this image and copyright information in PMC

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