Device indication for calcified coronary lesions based on coronary imaging findings

Abstract

Performing percutaneous coronary intervention (PCI) for heavily calcified coronary lesions remains a significant clinical challenge. In 2023, following the availability of intravascular lithotripsy (IVL), a consensus document was published outlining imaging-guided device selection strategies for the treatment of calcified lesions. Since the publication of that document, the DUAL-PREP study has demonstrated the safety of combining rotational atherectomy (rotablator) with IVL, a strategy previously contraindicated in the original consensus. As a result, a revision of the consensus document became necessary. In the updated consensus, the fundamental principle of imaging-guided treatment planning is retained. However, a key modification is the acknowledgment that IVL may now be considered in cases where post-atherectomy imaging reveals persistent heavy calcification and further atherectomy is deemed either ineffective or potentially harmful to the patient.

Keywords: Intravascular lithotripsy; Intravascular ultrasound; Optical coherence tomography; Optical frequency domain imaging; Orbital atherectomy; Rotational atherectomy.

Fig. 1

Device selection strategy for calcified lesions. *The criteria for IVL use after atherectomy are as follows: In addition to meeting criterion (1), the case must also satisfy either criterion (2) or (3): (1) Post-atherectomy imaging reveals a residual calcium score ≥ 3. (2) Further atherectomy is contraindicated due to clinical factors such as reduced left ventricular function or impaired renal function. (3) Additional atherectomy is unlikely to be effective based on lesion characteristics. **DES use is generally recommended after IVL use. IVUS intravascular ultrasound, OCT optical coherence tomography, OFDI optical frequency domain imaging, NC non-compliant, IVL intravascular lithotripsy, DES drug-eluting stent, DCB drug coated balloon