The following are key points to remember from a European clinical consensus statement on management strategies for heavily calcified coronary stenoses:

1. This current European Association of Percutaneous Cardiovascular Interventions (EAPCI) clinical consensus statement, prepared in collaboration with the EURO4C-PCR group, describes the comprehensive management of patients with heavily calcified coronary stenoses.
2. The mechanism of arterial calcification is complex and entails the apoptosis of macrophages within the lipid core and the dedifferentiation of vascular smooth muscle cells to an osteoblast phenotype, resulting in the development of surrounding sheets or nodules of calcium.
3. If moderate or severe calcification is noted on angiography or coronary computed tomography angiography (CCTA), the lesion should be assessed for crossability by small balloon. If the lesion can be crossed, pre-dilation should be performed. If pre-dilation is inadequate, consideration should be given to use of high pressure, cutting, scoring balloons or advanced plaque modification techniques (intravascular lithotripsy [IVL] and/or atherectomy devices). If the lesion cannot be crossed, primary wiring using rotawire or crossing using microcatheter should be done followed by rotational atherectomy. If rotawire or microcatheter will not cross, use of laser can be attempted. Intravascular ultrasound/optical coherence tomography (IVUS/OCT) should be used for stent optimization.
4. Although CCTA can predict an undilatable lesion and the need for lesion modification (per-lesion calcium score of ≥453), it remains underutilized in clinical practice. If IVUS or OCT catheters will pass, calcium burden should be assessed and can guide plaque modification technique.
5. The adjunctive use of advanced plaque modification techniques (IVL and/or atherectomy devices) before stent implantation is advised when the calcified lesion fulfils the IVUS or OCT criteria of high calcification burden with lumen narrowing.
6. On IVUS, a calcified plaque is detected as an area with high echogenicity, brighter than the reference adventitia, with acoustic shadowing of deeper vessel structures. IVUS can quantify calcification by the size of the circumferential arc and by the length of the calcified segment. OCT provides higher resolution than IVUS and detects calcified plaques as a low-intensity area with clear delineation. OCT can be used to quantify calcification by the size of the circumferential arc, thickness, longitudinal length, depth, area, and three-dimensional volume.
7. Cutting balloons (proximal lesions, aorto-ostial lesions, straight coronary segments) and scoring balloons (proximal and distal lesions, aorto-ostial lesions, tortuous coronary segments) can be used after rotational atherectomy (RA), orbital atherectomy (OA), or IVL.
8. The basic principle of atherectomy techniques is the ablation of calcific atherosclerotic plaques within the vessel lumen while also creating fractures and fissures. RA is used to modify lesion morphology by creating a polished channel that allows adequate balloon dilatation, calcium fracture, and optimal stent expansion and is therefore utilized for limited (rather than aggressive) debulking. OA uses a differential sanding mechanism to reduce the calcified plaque. A key aspect of OA is that it works bidirectionally, ablating plaques while being advanced and retracted. It is best suited for undilatable lesions and superficial or nodular calcification (by intravascular imaging).
9. Excimer laser coronary angioplasty is based on the emission of monochromatic coherent light in the ultraviolet range (wavelength 308 nm) able to ablate inorganic material and break molecular bonds. It can be useful for calcific lesion and within underexpanded stents.
10. IVL pulse is produced when lithotripsy emitters create vapor bubbles within the integrated balloon, resulting in the formation of acoustic shockwaves with peak acoustic pressures of ∼50 atm that propagate circumferentially and transmurally through soft tissue with minimal effect while imparting compressive stress on calcified plaques as the primary mechanism of calcium fracture. IVL is suitable for deep calcification, calcified nodules, large vessels, stent underexpansion (currently off-label indication), bifurcation lesions, if side-branch wire protection is mandatory, and aorto-ostial calcified stenoses.
11. Special considerations include:
    • Patients undergoing complex high-risk percutaneous coronary intervention (PCI) of calcified coronary stenoses with severely reduced left ventricular function or where an adequate blood pressure cannot be maintained might benefit from mechanical circulatory support.
    • In bifurcation lesions, protective side-branch wiring should be avoided during RA or OA of the main branch.
    • Advanced plaque modification techniques, if required, can be safely used in transcatheter aortic valve implantation (TAVI) patients undergoing PCI of calcified lesions.
    • Transradial arterial access is advised in PCI of calcified coronary lesions to reduce bleeding risk.

Clinical Topics: Interventions and Imaging, Invasive Cardiovascular Angiography and Intervention

Keywords: Coronary Stenosis, Plaque, Atherosclerotic

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