Two-year outcomes after percutaneous coronary intervention of calcified lesions with drug-eluting stents

Procedural safety of rotational atherectomy and modified balloon angioplasty: insights from a German national registry

BACKGROUND

Modified balloons (MB) and rotational atherectomy (RA) are recommended tools for treatment of coronary plaques with superficial calcium. Knowledge about in-hospital safety is limited.

METHODS

Patients with coronary artery disease who underwent coronary angiography with RA or MB angioplasty in Germany were identified via ICD and OPS codes from 2017 to 2020. Acute coronary syndromes were excluded. Since patients were not randomized toward MB or RA, potential confounding factors were taken into account using the propensity score methods. Thereby, inverse probability weighting was applied.

RESULTS

Ten thousand.ninety-twopatients underwent RA with an increasing trend from 1817 in 2017 toward 3166 in 2020. MBs were used in 22,378 patients also with an increasing trend from 4771 in 2017 toward 6078 in 2020. Patients receiving RA were older (74.23 ± 8.68 vs. 71.86 ± 10.02, p < 0.001), had a higher Charlson Comorbidity Index (2.07 ± 1.75 vs. 1.99 ± 1.76, p = 0.001) and more frequently left main (17.96% vs. 12.91%, p < 0.001) or three vessel disease (66.25% vs. 58.10%, p < 0.001). Adjusted procedural risk of major adverse cardiac and cerebrovascular events (MACCE) was similar in both groups, while pericardial effusion (RR 2.69; 95% CI 1.88-3.86, p < 0.001), pericardial puncture/pericardiotomy/pericardial tamponade (RR 2.66; 95% CI 1.85-3.81, p < 0.001) and bleeding (RR 1.65; 95% CI 1.12-2.43, p < 0.011) occurred more frequently in patients receiving RA. Patients treated with RA at high volume centers were hospitalized shorter (p = 0.005) and had a lower rate of acute cerebrovascular events (p < 0.001). Rate of MACCE, bleeding and pericardial puncture were not influenced by the annual RA numbers per center.

CONCLUSION

MBs had a lower risk of bleeding and pericardial puncture. Patients treated at centers with high annual RA procedure numbers had a lower risk of acute cerebrovascular events and were hospitalized shorter.

Coronary calcified nodules versus nonnodular coronary calcifications: a systematic review and meta-analysis

BACKGROUND

Percutaneous coronary intervention (PCI) on severely calcified coronary lesions is challenging. Coronary calcified nodule (CN) refers to an eccentric and protruding coronary calcification associated with plaque vulnerability and adverse clinical events. This study aims to conduct an extensive review of CNs, focusing on its prognostic impact in comparison with nonnodular coronary calcification (N-CN).

METHOD

A systematic literature review on PubMed, MEDLINE, and EMBASE databases was conducted for relevant articles. Observational studies or randomized controlled trials comparing CNs and N-CNs were included.

RESULTS

Five studies comparing CNs and N-CNs were pertinent for inclusion. The total number of individuals across these studies was 1456. There were no significant differences in the baseline demographic, clinical, and angiographic data between the CN and N-CN groups. Intracoronary imaging was always utilized. At follow-up, CNs were associated with significantly increased, target vessel revascularization [odds ratio (OR) 2.16; 95% confidence interval (CI): 1.39-3.36, P-value < 0.01, I2 = 0%] and stent thrombosis (OR 9.29; 95% CI: 1.67-51.79, P-value = 0.01, I2 = 0%) compared with N-CN. A trend for greater cardiac death was also assessed in the CN group (OR 1.75; 95% CI: 0.98-3.13, P-value = 0.06, I2 = 0%).

CONCLUSION

CN has a significantly negative impact on outcomes when compared with N-CN.

Drug-Eluting Balloons in Calcified Coronary Lesions: A Meta-Analysis of Clinical and Angiographic Outcomes

Background: The usefulness of drug-eluting balloons (DEBs) has not been fully elucidated in calcified coronary lesions (CCLs). This meta-analysis aimed to evaluate the efficacy of DEBs compared to a drug-eluting stent (DES) in this setting. Methods: PubMed, EMBASE and Cochrane were searched through December 2023. The primary endpoint was 12 months major adverse cardiac events (MACE). Secondary endpoints included clinical outcomes and angiographic results after PCI and at a 12-month follow-up. Results: Five studies and a total of 1141 patients with 1176 coronary lesions were included. Overall, the DEB was comparable to DES in MACE (RR = 0.86, 95% CI: 0.62-1.19, p = 0.36), cardiac death (RR = 0.59, 95% CI: 0.23-1.53, p = 0.28), myocardial infarction (RR = 0.89, 95% CI: 0.25-3.24, p = 0.87) and target lesion revascularization (RR = 1.1, 95% CI: 0.68-1.77, p = 0.70). Although the DEB was associated with worse acute angiographic outcomes (acute gain; MD = -0.65, 95% CI: -0.73, -0.56 and minimal lumen diameter; MD = -0.75, 95% CI: -0.89, -0.61), it showed better results at 12 months follow-up (late lumen loss; MD = -0.34, 95% CI: -0.62, -0.07). Conclusions: This meta-analysis showed that the DEB strategy is comparable to DES in the treatment of CCLs in terms of clinical outcomes. Although the DEB strategy had inferior acute angiographic results, it may offer better angiographic results at follow-up.

Endovascular Drug Delivery

Drug-eluting stents (DES) and balloons revolutionize atherosclerosis treatment by targeting hyperplastic tissue responses through effective local drug delivery strategies. This review examines approved and emerging endovascular devices, discussing drug release mechanisms and their impacts on arterial drug distribution. It emphasizes the crucial role of drug delivery in modern cardiovascular care and highlights how device technologies influence vascular behavior based on lesion morphology. The future holds promise for lesion-specific treatments, particularly in the superficial femoral artery, with recent CE-marked devices showing encouraging results. Exciting strategies and new patents focus on local drug delivery to prevent restenosis, shaping the future of interventional outcomes. In summary, as we navigate the ever-evolving landscape of cardiovascular intervention, it becomes increasingly evident that the future lies in tailoring treatments to the specific characteristics of each lesion. By leveraging cutting-edge technologies and harnessing the potential of localized drug delivery, we stand poised to usher in a new era of precision medicine in vascular intervention.

Management of Calcified Coronary Lesions

With an aging population, coronary calcification is increasingly encountered in modern day interventional practice. Unfortunately, it is associated with lower procedural success and higher rates of periprocedural complications, such as failure to deliver stents, perforations, dissections, and other major adverse cardiac events. Furthermore, suboptimal stent deployment in the setting of severe calcification is associated with both short-and long-term major adverse cardiac events, including stent thrombosis, MI, in-stent restenosis, and target lesion revascularization. A variety of treatment options for these lesions exist, including specialized balloons, atherectomy, and intravascular lithotripsy. While there is currently no universally accepted algorithm for choosing between these treatment strategies, several different algorithms exist, and the optimization of these treatment regimens will continue to evolve in the coming years. This review aims to provide insights on the different therapeutic modalities and an understanding of the current body of evidence.

Coronary calcification in patients presenting with acute coronary syndromes: insights from the MATRIX trial

AIMS

The role of coronary calcification on clinical outcomes among different revascularization strategies in patients presenting with acute coronary syndromes (ACSs) has been rarely investigated. The aim of this investigation is to evaluate the role of coronary calcification, detected by coronary angiography, in the whole spectrum of patients presenting with acute ACS.

METHODS AND RESULTS

The present study was a post hoc analysis of the MATRIX programme. The primary endpoint was major adverse cardiovascular events (MACE), defined as the composite of all-cause mortality, myocardial infarction (MI), or stroke up to 365 days. Among the 8404 patients randomized in the MATRIX trial, data about coronary calcification were available in 7446 (88.6%) and therefore were included in this post hoc analysis. Overall, 875 patients (11.7%) presented with severe coronary calcification, while 6571 patients (88.3%) did not present severe coronary calcification on coronary angiography. Fewer patients with severe coronary calcification underwent percutaneous coronary intervention whereas coronary artery bypass grafting or medical therapy-only was more frequent compared with patients without severe calcification. At 1-year follow-up, MACE occurred in 237 (27.1%) patients with severe calcified coronary lesions and 985 (15%) patients without severe coronary calcified lesions [hazard ratio (HR) 1.91; 95% confidence interval (CI) 1.66-2.20, P < 0.001]. All-cause mortality was 8.6% in patients presenting with and 3.7% in those without severe coronary calcification (HR 2.38, 1.84-3.09, P < 0.001). Patients with severe coronary calcification incurred higher rate of MI (20.1% vs. 11.5%, HR 1.81; 95% CI 1.53-2.1, P < 0.001) and similar rate of stroke (0.8% vs. 0.6%, HR 1.35; 95% CI 0.61-3.02, P = 0.46).

CONCLUSION

Patients with ACS and severe coronary calcification, as compared to those without, are associated with worse clinical outcomes irrespective of the management strategy.

Management strategies for heavily calcified coronary stenoses: an EAPCI clinical consensus statement in collaboration with the EURO4C-PCR group

Since the publication of the 2015 EAPCI consensus on rotational atherectomy, the number of percutaneous coronary interventions (PCI) performed in patients with severely calcified coronary artery disease has grown substantially. This has been prompted on one side by the clinical demand for the continuous increase in life expectancy, the sustained expansion of the primary PCI networks worldwide, and the routine performance of revascularization procedures in elderly patients; on the other side, the availability of new and dedicated technologies such as orbital atherectomy and intravascular lithotripsy, as well as the optimization of the rotational atherectomy system, has increased operators' confidence in attempting more challenging PCI. This current EAPCI clinical consensus statement prepared in collaboration with the EURO4C-PCR group describes the comprehensive management of patients with heavily calcified coronary stenoses, starting with how to use non-invasive and invasive imaging to assess calcium burden and inform procedural planning. Objective and practical guidance is provided on the selection of the optimal interventional tool and technique based on the specific calcium morphology and anatomic location. Finally, the specific clinical implications of treating these patients are considered, including the prevention and management of complications and the importance of adequate training and education.

The Role of Intracoronary Imaging for the Management of Calcified Lesions

Interventional cardiologists in everyday practice are often confronted with calcified coronary lesions indicated for percutaneous transluminal coronary angioplasty (PTCA). PTCA of calcified lesions is associated with diverse technical challenges resulting in suboptimal coronary stenting and adverse long-term clinical outcomes. Angiography itself offers limited information regarding coronary calcification, and the adjuvant use of intracoronary imaging such as intravascular ultrasound (IVUS) and Optical Coherence Tomography (OCT) can guide the treatment of calcified coronary lesions, optimizing the different stages of the procedure. This review offers a description of why, when, and how to use intracoronary imaging for PTCA of calcified coronary lesions in order to obtain the most favorable results. We used the PubMed and Google Scholar databases to search for relevant articles. Keywords were calcified coronary lesions, intracoronary imaging, IVUS, OCT, coronary calcium modification techniques, PTCA, and artificial intelligence in intracoronary imaging. A total of 192 articles were identified. Ninety-one were excluded because of repetitive or non-important information.

Drug-coated balloon strategy following orbital atherectomy for calcified coronary artery compared with drug-eluting stent: One-year outcomes and optical coherence tomography assessment

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.

Impact of Eruptive vs Noneruptive Calcified Nodule Morphology on Acute and Long-Term Outcomes After Stenting

BACKGROUND

Whether an eruptive or noneruptive target lesion calcified nodule (CN) portends worse acute and long-term clinical outcomes after stenting has not been established.

OBJECTIVES

The authors sought to compare acute and long-term clinical outcomes in eruptive CN vs noneruptive CN morphology.

METHODS

Using optical coherence tomography, an eruptive CN was defined as an accumulation of small calcium fragments protruding and disrupting the overlying fibrous cap, typically with small amount of thrombus. A noneruptive CN was defined as an accumulation of small calcium fragments with a smooth intact fibrous cap without an overlying thrombus. The primary endpoint was target lesion failure (TLF) including cardiac death, target vessel myocardial infarction, or clinically driven target lesion revascularization in patients with ≥6-month follow-up.

RESULTS

Among 3,231 patients with evaluable pre- and postintervention OCT, 236 patients had lesions with CNs (7.3%). After eliminating 4 secondary lesions and 6 patients without ≥6-month follow-up, 126 (54.8%) lesions with eruptive CNs and 104 (45.2%) lesions with noneruptive CNs formed the current report. Compared with noneruptive CNs, eruptive CNs were independently associated with greater stent expansion (89.2% ± 18.7% vs. 81.5% ± 18.9%; P = 0.003) after adjusting for morphologic and procedural factors. At 2 years, eruptive CNs trended toward more TLF compared with noneruptive CNs (Kaplan-Meier estimates, 19.8% vs 12.5%; P = 0.11) and significantly more target lesion revascularization (18.3% vs 9.6%; P = 0.04). In the adjusted model, eruptive CNs were independently associated with 2-year TLF (HR: 2.07; 95% CI: 1.01-4.50; P = 0.048).

CONCLUSIONS

Compared with noneruptive CN morphology, lesions with an eruptive CN appearance on optical coherence tomography had a worse poststent long-term clinical outcome despite better acute stent expansion.

Outcomes after Percutaneous Coronary Intervention in Patients with Extremely Calcified Left Main Lesions

Background and Objectives: Available data with regard to the outcomes of patients with severely calcified left main (LM) lesions after revascularization by percutaneous coronary intervention (PCI) when compared to non-calcified LM lesions is unclear. Materials and Methods: The present study sought to retrospectively investigate in hospital and 1 year post-intervention outcomes of patients with extremely calcified LM lesions after PCI facilitated by calcium-dedicated devices (CdD). Seventy consecutive patients with LM PCI were included. CdD requirement was based on suboptimal results after balloon angioplasty. Results: Twenty-two patients (31.4%) required at least one CdD, while nine patients (12.8%) required at least two. Intravascular lithotripsy and rotational atherectomy were the predominantly used methods(59.1% and 40.9% respectively, for in-group ratios), while ultra-high pressure and scoring balloons contributed the least to lesion preparation (9%). In 20 patients (28.5%), severe or moderate calcifications were angiographically identified, but non-compliant balloon predilation was adequate and CdD were not necessary. Total procedural time was significantly higher in CdD group (p-value 0.02). Procedural and clinical success were obtained in 100% of cases. There were no major adverse cardiac and cerebrovascular events (MACCE) recorded during hospitalization. MACCE at 1 year post-procedure were recorded in three patients (4.2% overall). All three events were documented in the control group (6.2%), and no events were recorded in CdD group (p-value 0.23). There was one cardiac death at 10 months and two target lesion revascularizations for side-branch restenosis. Conclusions: Patients with extremely calcified LM lesions treated by PCI present a favorable prognosis if angioplasty is facilitated by more aggressive lesion debulking using calcium-dedicated devices.

Preliminary study of the significance of reverberation by IVUS detection for patients with severe calcified lesions

To explore the potential significance of the reverberation of calcification by comparing both intravascular ultrasound (IVUS) and optical coherence tomography (OCT) measurement post manual coregistration. The reverberation phenomenon is often detected by IVUS for severe calcified lesions post rotational atherectomy (RA), which is thought to be due to the glassy and smooth inner surfaces of calcifications. Because of the poor penetration of IVUS, it is impossible to measure the thickness of calcifications, and the relationship between multiple reverberations and the thickness of calcification lesions has not been reported before. A total of forty-nine patients with severe calcified coronary lesions that were detected by IVUS and OCT simultaneously were enrolled in our retrospective study. If reverberation phenomena were detected by IVUS, intravascular imaging (IVI) data (including distance between the IVUS catheter center and the inner surface of the reverberation signal, the intervals between all adjacent reverberation signals, the number of layers of reverberation in IVUS, and the thickness of the calcification in OCT) were measured at the same position and same direction (each cross-section had 4 mutually perpendicular directions) at 1-mm intervals. The correlation between each reverberation observational value and OCT data was the primary target in this retrospective study, and the correlation between reverberation and calcium crack post predilatation was analyzed in other 15 patients. Four hundred twenty-eight valid observational points were analyzed simultaneously by IVUS and OCT; among them, 300 points had a single layer of reverberation, 83 had double layers of reverberation and 42 had multiple layers (≥ 3 layers) of reverberation by IVUS detection post-RA. Multivariate logistic regression analysis showed that the number of layers of reverberation by IVUS was significantly related to the thickness of calcifications by OCT at the same point and in the same direction (p < 0.001). Single, double, and multiple layers of reverberation in IVUS correspond to median calcification thicknesses (interquartile ranges (IQRs)) of 0.620 mm (0.520-0.720), 0.950 mm (0.840-1.040) and 1.185 mm (1.068-1.373), respectively, by OCT detection. Another 100 points in other 15 patients with integrated IVUS data pre- and post-predilatation showed that only single layer of reverberation was related to calcium crack (p < 0.001). The number of layers of reverberation signal detected by IVUS is positively correlated with the thickness of calcifications measured by OCT post-RA and single layer of reverberation is correlated to calcium crack post-predilatation.

Ten-year clinical outcomes of drug-eluting stents with different polymer coating strategies by degree of coronary calcification: a pooled analysis of the ISAR-TEST 4 and 5 randomised trials

BACKGROUND

Long-term data concerning the efficacy of different polymer-coating strategies of new-generation drug-eluting stents (DES) in patients with coronary artery calcification (CAC) are scant.

AIMS

We aimed to investigate 10-year outcomes by degree of CAC after new-generation DES implantation with different polymer-coating strategies.

METHODS

We analysed individual patient and lesion characteristics of patients randomised to treatment with polymer-free sirolimus-eluting, biodegradable-polymer sirolimus-eluting and permanent-polymer zotarolimus- or everolimus-eluting stents. Endpoints of interest at 10 years were all-cause mortality, myocardial infarction (MI), target lesion revascularisation (TLR) and definite or probable stent thrombosis (ST) according to the degree of CAC (no, mild, moderate or severe) and coating strategy (polymer-free vs biodegradable-polymer vs permanent-polymer).

RESULTS

A total of 4,953 patients with 6,924 lesions were included. No, mild, moderate or severe CAC was present in 24.5%, 41.8%, 25.8% and 8.0% of patients, respectively. At 10-year follow-up, overall event rates were high, with an incremental increase according to the degree of CAC (all-cause mortality: no 25.3%, mild 32.1%, moderate 41.7%, severe CAC 46.5%; adjusted [adj.] p=0.004; TLR: no 17.4%, mild 16.5%, moderate 19.8%, severe CAC 28.7%; adj. p=0.001; MI: no 4.9%, mild 5.9%, moderate 6.0%, severe CAC 10.5%; adj. p=0.02; and ST: no 1.3%, mild 1.4%, moderate 1.8%, severe CAC 3.6%; adj. p=0.57). In patients with moderate-severe CAC, event rates were comparable, regardless of the DES polymer-coating strategy.

CONCLUSIONS

At 10 years after PCI with new-generation DES, there was an incremental increase in adverse events by degree of coronary calcification. These detrimental effects do not seem to be impacted by different polymer-coating strategies.

Five-year outcomes of biodegradable versus second-generation durable polymer drug-eluting stents used in complex percutaneous coronary intervention

BACKGROUND

There are few data comparing clinical outcomes of complex percutaneous coronary intervention (CPCI) when using biodegradable polymer drug-eluting stents (BP-DES) or second-generation durable polymer drug-eluting stents (DP-DES). The purpose of this study was to investigate the safety and efficacy of BP-DES and compare that with DP-DES in patients with and without CPCI during a 5-year follow-up.

METHODS

Patients who exclusively underwent BP-DES or DP-DES implantation in 2013 at Fuwai Hospital were consecutively enrolled and stratified into two categories based on CPCI presence or absence. CPCI included at least one of the following features: unprotected left main lesion, ≥2 lesions treated, ≥2 stents implanted, total stent length >40 mm, moderate-to-severe calcified lesion, chronic total occlusion, or bifurcated target lesion. The primary endpoint was major adverse cardiac events (MACE) including all-cause death, recurrent myocardial infarction, and total coronary revascularization (target lesion revascularization, target vessel revascularization [TVR], and non-TVR) during the 5-year follow-up. The secondary endpoint was total coronary revascularization.

RESULTS

Among the 7712 patients included, 4882 (63.3%) underwent CPCI. Compared with non-CPCI patients, CPCI patients had higher 2- and 5-year incidences of MACE and total coronary revascularization. Following multivariable adjustment including stent type, CPCI was an independent predictor of MACE (adjusted hazard ratio [aHR]: 1.151; 95% confidence interval [CI]: 1.017-1.303, P  = 0.026) and total coronary revascularization (aHR: 1.199; 95% CI: 1.037-1.388, P  = 0.014) at 5 years. The results were consistent at the 2-year endpoints. In patients with CPCI, BP-DES use was associated with significantly higher MACE rates at 5 years (aHR: 1.256; 95% CI: 1.078-1.462, P  = 0.003) and total coronary revascularization (aHR: 1.257; 95% CI: 1.052-1.502, P  = 0.012) compared with that of DP-DES, but there was a similar risk at 2 years. However, BP-DES had comparable safety and efficacy profiles including MACE and total coronary revascularization compared with DP-DES in patients with non-CPCI at 2 and 5 years.

CONCLUSIONS

Patients underwent CPCI remained at a higher risk of mid- to long-term adverse events regardless of the stent type. The effect of BP-DES compared with DP-DES on outcomes was similar in CPCI and non-CPCI patients at 2 years but had inconsistent effects at the 5-year clinical endpoints.

Pulsatile intravascular lithotripsy: A novel mechanism for peripheral artery calcium fragmentation and luminal expansion

OBJECTIVE

To assess the feasibility and treatment effect of pulsatile intravascular lithotripsy (PIVL) on calcified lesions in a cadaveric model of peripheral artery disease.

BACKGROUND

PIVL represents a novel potential approach to intravascular lithotripsy for the treatment of vascular calcification.

METHODS

In this preclinical device-feasibility study, technical success, calcium morphology and luminal expansion before and after PIVL treatment were evaluated in surgically isolated, perfused atherosclerotic lower-leg arteries and in perfused whole cadaveric lower legs. Analytical methods included micro-computed tomography (μCT), intravascular optical coherence tomography, digital subtraction angiography, and quantitative coronary analysis.

RESULTS

Treatment delivery was successful in all whole-leg specimens (N = 6; mean age 74.2, 66 % female) and in the 8 excised vessels with diameter appropriate to the PIVL balloon (2 vessels exceeding diameter specifications were excluded). There were no vessel perforations. After PIVL, excised vessels showed extensive evidence of new, full-thickness fractures in lesions with calcium arc exceeding 152° and with calcium wall thickness between 0.24 mm and 1.42 mm. PIVL fractures were observed in intimal nodules, sheets, shingles, and medial plates. Vessels within whole-leg specimens also showed full-thickness fracturing and a mean of 1.9 ± 0.9 mm in acute luminal gain, 101.6 ± 99.5 % gain in total minimum cross-sectional area, and a 31.7 ± 13.4 % relative reduction in stenosis (P < 0.001 for all analyses).

CONCLUSIONS

In a cadaveric model, PIVL treatment was technically feasible, fractured both circumferential and eccentric calcium lesions, and resulted in acute luminal gain. A clinical feasibility study of PIVL is currently enrolling.

A case of covered stent failure in sealing up a coronary perforation potentially related to intravascular lithotripsy treatment: insights from optical coherence tomography

BACKGROUND

Intravascular lithotripsy (IVL) is a new modality in treatment of calcified coronary lesions which improves procedural outcomes. Coronary perforation is an extremely uncommon but potentially catastrophic complication of percutaneous coronary intervention (PCI) and IVL therapy.

CASE SUMMARY

We report a case of an elective PCI to a calcified left anterior descending (LAD) and diagonal bifurcation lesion in a 65-year-old man. LAD was treated with two stents. Despite high pressure non-compliant balloon inflation, a focal area of under-expansion remained. IVL successfully treated the under-expansion but was complicated with a large coronary perforation. The perforation was successfully sealed with a PK-PAPYRUS covered stent sacrificing the diagonal branch. Patient remained stable until 3 hours later when he developed tamponade requiring urgent pericardial drainage. Repeat angiography demonstrated recanalization of the diagonal branch and ongoing contrast extravasation along its course. Optical coherence tomography intracoronary imaging was used to delineate the mechanism of ongoing bleeding. This demonstrated an interrupted elastic membrane of the covered stent, potentially caused by underlying fractured calcium. Therefore, a second overlying PAPYRUS stent was deployed which satisfactorily sealed the perforation.

DISCUSSION

IVL is an emerging less invasive treatment for calcified coronary stenosis but could be associated with drastic complications. This case highlights the importance of awareness of IVL-related coronary perforation and the potential limitation of new generation thinner-wall covered stents. Intracoronary imaging plays an important role in identifying mechanisms of stent failure, tailoring treatment, and optimizing outcomes.

Intravascular lithotripsy for coronary calcium: A case report and review of the literature

BACKGROUND

Coronary calcium poses a challenge for the interventional cardiologist often leading to stent under-expansion and subsequent ischemic events. Aggressive balloon post-dilatation though helpful is usually inadequate. Multiple plaque ablation techniques are in vogue, but they are technically demanding and are not without complications. Shockwave intravascular lithotripsy (S-IVL) has emerged as a user-friendly and effective mechanism for calcium management with a high safety margin. A series of trials (DISRUPT CAD I-IV) have demonstrated both short-term and long-term safety and efficacy of the technique. As experience with the technique grows more and more, therapy areas like stent restenosis are being covered by the S-IVL.

CASE SUMMARY

We report a series of 2 cases successfully managed with S-IVL therapy at our center. The first case is of a 57-year-old smoker who presented with acute coronary syndrome. His left anterior descending coronary artery revealed calcified 90% stenosis on angiogram and a combination of superficial-deep calcium on intracoronary imaging. The calcium was treated with 20 pulses of S-IVL to create discontinuity and a sirolimus eluting drug-eluting stent was successfully implanted. The second case is that of an elderly lady who presented with stable angina and demonstrated diffuse calcified lesions in the left anterior descending artery on angiogram. She also demonstrated a mixture of superficial and deep seated calcium zones on imaging. S-IVL therapy was applied to generate fractures in calcium, and two overlapping drug-eluting stents were implanted successfully without any complications.

CONCLUSION

S-IVL is an emerging, efficient, user-friendly and safe therapy for managing intracoronary calcium in routine interventional practice.

Relationship between Metabolic Syndrome and Clinical Outcome in Patients Treated with Drug-Eluting Stenting after Rotational Atherectomy for Complex Calcified Coronary Lesions

Background and aims: although an association between metabolic syndrome (MS) and cardiovascular disease risk has been documented, the relationship in patients with complex calcified coronary lesions undergoing rotational atherectomy (RA) and drug-eluting stent(DES) insertion remains controversial. Here, the influence of MS on outcomes was assessed. Methods and results: we retrospectively included 398 patients who underwent RA and DES insertion for complex calcified coronary lesions in our institution between June 2015 and January 2019. The modified Adult Treatment Plan III was used to diagnose MS. The endpoint was major adverse cardiovascular events (MACEs), comprising mortality from all causes, myocardial infarction, and target vessel revascularization (TVR). In all, 173 (43.5%) patients had MS. MS was significantly associated with MACE over the 28.32 ± 6.79-month follow-up period (HR 1.783, 95% CI from 1.122 to 2.833) even after adjustment for other possible confounders. Conclusion: MS was frequently observed in patients treated with RA with DES insertion for complex calcified coronary lesions. MS independently predicted MACE in these patients.

Clinical Outcomes of Different Calcified Culprit Plaques in Patients with Acute Coronary Syndrome

Background: Previous studies have found that coronary artery calcification is closely associated with the occurrence of major adverse cardiac events (MACE). This study aimed to investigate the characteristics and clinical outcomes of different calcified plaques in patients with acute coronary syndrome (ACS) by using optical coherence tomography (OCT). Methods: 258 ACS patients with calcified culprit plaques who underwent OCT-guided stent implantation were enrolled. They were divided into three subtypes based on the calcified plaque morphology, including eruptive calcified nodules, calcified protrusion, and superficial calcific sheet. Results: Compared with superficial calcific sheet and calcified protrusion, eruptive calcified nodules had the greatest calcium burden and a higher rate of stent edge dissection (p < 0.001) and incomplete stent apposition (p < 0.001). In a median follow-up period of 2 years, 39 (15.1%) patients experienced MACE (a composite event of cardiac death, target-vessel myocardial infarction, ischemia-driven revascularization), with a significantly higher incidence in the eruptive calcified nodules group (32.1% vs. 10.1% vs. 13.0%, p = 0.001). A multivariate Cox analysis demonstrated that the eruptive calcified nodules (hazard ratio 3.14; 95% confidence interval, 1.64−6.02; p = 0.001) were an independent predictor of MACE. Conclusions: MACE occurred more frequently in ACS patients with eruptive calcified nodules, and the eruptive calcified nodules were an independent predictor of MACE.

Randomized evaluation of vessel preparation with orbital atherectomy prior to drug-eluting stent implantation in severely calcified coronary artery lesions: Design and rationale of the ECLIPSE trial

BACKGROUND

Severe coronary artery calcification has been associated with stent underexpansion, procedural complications, and increased rates of early and late adverse clinical events in patients undergoing percutaneous coronary intervention. To date, no lesion preparation strategy has been shown to definitively improve outcomes of percutaneous coronary intervention for calcified coronary artery lesions.

STUDY DESIGN AND OBJECTIVES

ECLIPSE (NCT03108456) is a prospective, randomized, multicenter trial designed to evaluate two different vessel preparation strategies in severely calcified coronary artery lesions. The routine use of the Diamondback 360 Coronary Orbital Atherectomy System is compared with conventional balloon angioplasty prior to drug-eluting stent implantation. The trial aims to enroll approximately 2000 subjects with a primary clinical endpoint of target vessel failure, defined as the composite of cardiac death, target vessel-related myocardial infarction, or ischemia-driven target vessel revascularization assessed at 1 year. The co-primary endpoint is the acute post-procedural in-stent minimal cross-sectional area as assessed by optical coherence tomography in a 500-subject cohort. Enrollment is anticipated to complete in 2022 with total clinical follow-up planned for 2 years.

CONCLUSIONS

ECLIPSE is a large-scale, prospective randomized trial powered to demonstrate whether a vessel preparation strategy of routine orbital atherectomy system is superior to conventional balloon angioplasty prior to implantation of drug-eluting stents in severely calcified coronary artery lesions.

Contemporary Evidence-Based Diagnosis and Management of Severe Coronary Artery Calcification

Percutaneous treatment of heavily calcified coronary lesions remains a challenge for interventional cardiologists with increased risk of incomplete lesion preparation, suboptimal stent deployment, procedural complications, and a higher rate of acute and late stent failure. Adequate lesion preparation through calcium modification is crucial in optimising procedural outcomes. Several calcium modification devices and techniques exist, with rotational atherectomy the predominant treatment for severely calcified lesions. Novel technologies such as intravascular lithotripsy are now available and show promise as a less technical and highly effective approach for calcium modification. Emerging evidence also emphasises the value of detailed characterisation of calcification severity and distribution especially with intracoronary imaging for appropriate device selection and individualised treatment strategy. This review aims to provide an overview of the non-invasive and invasive evaluation of coronary calcification, discuss calcium modification techniques and propose an algorithm for the management of calcified coronary lesions.

Incidence and prognostic impact of the calcified nodule in coronary artery disease patients with end-stage renal disease on dialysis

Coronary artery calcification is frequently observed in coronary artery disease (CAD) patients with end-stage renal disease (ESRD). Calcified nodule (CN) is recognized as one of the vulnerable plaque characteristics responsible for acute coronary syndrome (ACS). Although CN is a cause of ACS in only 10%, its prevalence may be higher in elderly patients and/or ESRD. The aim of this study is to investigate incidence, clinical characteristics, and prognostic impact of CN in CAD patients with ESRD on dialysis. A total of 51 vessels from 49 CAD patients with ESRD on dialysis were enrolled in this study. CN was defined as a high-backscattering mass protruding into the lumen with a strong signal attenuation and an irregular surface by optical coherence tomography. Incidence, clinical characteristics and prognosis of patients with CN were studied. Major adverse cardiac events (MACE) were defined as a composite of all-cause death, non-fatal myocardial infarction, target vessel revascularization (TVR) and stroke. CNs were observed in 30 vessels from 29 patients (59.2%). Duration of dialysis was significantly longer in CN group than in non-CN group (P = 0.03). Overall, all-cause death, cardiac death, TVR and MACE occurred in 7 (14.3%), 3 (6.1%), 11 (22.4%) and 16 (32.7%) patients during follow-up (median 826 days), respectively. Kaplan-Meier survival analysis revealed that MACE-free survival was significantly lower in patients with CN compared with those without CN (Log-rank, P = 0.036).In conclusion, CN was observed in about 60% of the CAD patients with ESRD and was associated with duration of dialysis and worse prognosis.

Impact of Hemodialysis Duration on Coronary Artery Calcification Among Hemodialysis Patients Who Underwent Percutaneous Coronary Intervention

Our study aimed to evaluate the prevalence and impact of coronary artery calcification (CAC) on hemodialysis (HD) patients with coronary artery disease (CAD) who underwent percutaneous coronary intervention (PCI). We enrolled 211 HD patients who underwent PCI (men: n = 155, age: 71 ± 1 0 years). Severe CAC was defined as calcification with an arc of 360° on intravascular ultrasound. Multivariate analysis was performed to determine the predictors of severe CAC. The impact of severe CAC on target lesion revascularization (TLR) was evaluated. Patients with severe CAC (46%) had a higher incidence of diabetes mellitus (DM) (79 vs 59%, P = .003) and longer HD duration (7.7 vs 3.4 years, P < .001) than those with non-severe CAC. Multivariate analysis demonstrated that DM, HD duration, and angiographic calcification were significant predictors for severe CAC (odds ratio 4.42, 1.13, and 6.62; P < .001, P < .001, and P < .001, respectively). After the median follow-up period of 580 days (interquartile range, 302-730 days), Kaplan-Meier curve analysis revealed that severe CAC was associated with an increased risk for TLR (χ² 12.7; P = .002). In HD patients with CAD after PCI, DM and HD duration were significant predictors for severe CAC. Furthermore, severe CAC was associated with an increased risk for TLR.

Early Australian experience with intravascular lithotripsy treatment of severe calcific coronary stenosis: IVL in acute/chronic coronary syndromes

AIMS

Calcified coronary stenoses are a serious impediment to optimal stent expansion and can lead to stent failure and catastrophic adverse outcomes. We hereby present early Australian experience with intravascular lithotripsy for the treatment of calcific lesions in acute and chronic coronary syndromes.

METHODS AND RESULTS

This was a single-centre retrospective study of all patients treated with intravascular lithotripsy (IVL) between October 2019 and June 2021. Patient demographics, procedural variables, and treatment safety/efficacy outcomes were evaluated. During this period, there were 40 patients and 41 coronary lesions with IVL-assisted percutaneous coronary intervention (PCI) (70% male; mean age 72.8±9.5 years). Indications for PCI were acute coronary syndromes in 25 patients (62.5%), and stable angina in 15 patients (37.5%). Upfront IVL usage occurred in 5% of cases with the rest being bailout procedures due to suboptimal initial balloon predilatation or stent underexpansion. Angiographic success (<20% residual stenosis) occurred in 37 cases (92.5%), with mean residual stenosis of 8.25%±8.5%. Two patients experienced procedural complications (5%).

CONCLUSIONS

IVL appears to be a safe and effective modality in modifying coronary calcium to achieve optimal stent expansion in real-world practice. This device obviates the need for more complex lesion preparation strategies such as rotational or orbital atherectomy.

Intravascular Lithotripsy in Calcified Coronary Lesions: A Single-Center Experience in “Real-World” Patients

Objectives

This study aims to describe the outcome of intravascular lithotripsy (IVL) when used with different indications and to assess the short- and long-term outcomes of IVL-facilitated percutaneous coronary intervention (PCI).

Background

Intravascular lithotripsy can improve the results of PCI of calcified coronary lesions with a low rate of periprocedural complications.

Methods

A total of 105 consecutive patients with 110 calcified lesions underwent IVL. A total of 87 de novo lesions were treated by IVL with the following indications: 25 before attempting other balloon-based devices (primary IVL), 51 after the failure of non-compliant balloon dilatation (secondary IVL), and 11 after stent implantation because of stent under expansion (bailout IVL). In 23 lesions, IVL was used for the treatment of in-stent restenosis (ISR). Effectiveness (angiographic success) and safety [major adverse cardiovascular events (MACEs) and IVL-related procedural complications] endpoints were assessed.

Results

Angiographic success was achieved in 84.6% of lesions. Early MACEs were periprocedural MI only, ranging from 6.7 to 20% depending on MI definition. The flow-limiting dissections rate was 2.7%. A total of five (4.5%) IVL balloons ruptured during treatment with subsequent vessel perforation in 1 case. MACEs at 12 months were 13.3%, with TLR occurring in 8 lesions (12% primary IVL, 0% secondary IVL, 0% bailout IVL, and 21.7% IVL for ISR, p = 0.002).

Conclusion

Treatment of calcified coronary lesions with IVL in a “real-world” setting can be performed with high success, low rate of procedural complications, and an acceptable MACEs rate. Target lesion failure may be more frequent when IVL is performed for the treatment of ISR due to calcium-mediated stent under expansion.

Physiological and angiographic outcomes of PCI in calcified lesions after rotational atherectomy or intravascular lithotripsy

BACKGROUND

Percutaneous coronary interventions (PCI) in calcified coronary artery lesions are associated with impaired stent expansion, higher rate of periprocedural complications and cardiac mortality. Lesion preparation using calcium modifying techniques such as Rotational Atherectomy (RA) or Intravascular Lithotripsy (IVL) has been advocated. Studies comparing these technologies are lacking. We aimed to compare the in-stent pressure gradient, evaluated by virtual fractional flow-reserve, in calcific lesions treated using either RA or IVL.

METHODS

Patients undergoing either RA- or IVL-assisted PCI from two European centers were included. Propensity score matching (1:2) was performed to control for potential bias. Primary outcome was post- PCI in-stent pressure gradient calculated by virtual fractional flow reserve (vFFRgrad). Secondary outcomes included the proportion of patients with complete functional revascularization defined as of distal vFFR post PCI (vFFRpost) ≥ 0.90.

RESULTS

From a cohort of 210 patients, 105 matched patients (70 RA and 35 IVL) were included. Pre-PCI vFFR did not differ between groups (0,65 ± 0,13 RA and 0,67 ± 0,11 IVL). After PCI, in-stent pressure gradients were significantly lower in the IVL group (0.032 ± 0.026 vs 0.043 ± 0.026 in the RA group, p = 0.024). The proportions of vessels with functional complete revascularization was similar between the two groups (32.9% vs. 37.1% in the RA and IVL group, respectively; p = 0.669).

CONCLUSIONS

Calcific lesions preparation with IVL is effective and resulted in improved in-stent pressure gradient compared to RA. Approximately one third of the patients undergoing PCI for a severely calcified lesion achieved functional revascularization with no difference between rotational RA and IVL.

Incidence and characteristics of incomplete stent apposition in calcified lesions: An optical coherence tomography study

BACKGROUND

Persistent or late acquired incomplete stent apposition (ISA) may be associated with late or very late stent thrombosis following drug-eluting stent implantation. Presence of calcium at the target lesion may increase the risk of ISA even after rotational atherectomy (RA) followed by stenting with high pressure balloon inflation. The aim of this study is to examine the incidence and characteristics of ISA in heavily calcified lesions.

METHODS

A total of 52 heavily calcified coronary artery lesions requiring RA plus stenting were selected and studied. After successful ablation followed by stent implantation, optical coherence tomography (OCT) was performed to assess stent expansion and apposition. Presence or absence of ISA was examined and maximal stent strut to vessel wall distance (max SV distance) was measured. In lesions with repeated OCT at follow-up, serial changes in ISA were investigated.

RESULTS

ISA was documented in 51 of 52 (98%) lesions. Mean max SV distance was 713 ± 371 μm. In lesions with serial OCT images (n = 11), max SV distance decreased significantly (692.1 ± 420.2 to 462.5 ± 387.0 μm, P < 0.01) but persisted in all but 2 lesions (82%).

CONCLUSIONS

ISA is frequently documented in heavily calcified lesions requiring RA. Significant ISA still persisted with minimal improvement in SV distance at follow-up. Prognostic impact of the persistent ISA in such calcified lesions needs further investigations.

Super high-pressure balloon versus scoring balloon to prepare severely calcified coronary lesions: the ISAR-CALC randomised trial

BACKGROUND

The comparative efficacy of balloon-based techniques to prepare severely calcified coronary lesions before stenting remains poorly studied.

AIMS

We sought to compare stent expansion following preparation of severely calcified coronary lesions with either a super high-pressure balloon or a scoring balloon.

METHODS

In this randomised, open-label trial, patients with severely calcified coronary lesions were enrolled at five centres in Germany and Switzerland. After unsuccessful lesion preparation with a standard non-compliant balloon (<30% reduction of baseline diameter stenosis), participants were randomised to predilation with either a super high-pressure balloon or a scoring balloon before drug-eluting stent (DES) implantation. The primary endpoint of the study was stent expansion index as assessed by optical coherence tomography (OCT). The key secondary endpoints included angiographic, strategy and procedural success.

RESULTS

OCT data after DES implantation were available for 70 out of 74 patients (94.6%) enrolled. Lesion preparation with a super high-pressure balloon versus a scoring balloon led to a comparable stent expansion index (0.72±0.12 vs 0.68±0.13; p=0.22). Compared with the scoring balloon, the super high-pressure balloon increased the minimum lumen diameter (2.83±0.34 mm vs 2.65±0.36 mm; p=0.03) and reduced the diameter stenosis (11.6±4.8% vs 14.4±5.6%; p=0.02) without difference in terms of angiographic success (100% vs 97.3%; p>0.99). Strategy success (91.9% vs 83.8%; p=0.48) and procedural success (100% vs 89.2%; p=0.12) were numerically more frequent with the super high-pressure balloon versus the scoring balloon.

CONCLUSIONS

In patients with severely calcified coronary artery lesions, preparation with a super high-pressure balloon versus a scoring balloon was associated with comparable stent expansion on intravascular imaging and a trend towards improved angiographic performance. Visual summary. A ComparIson of Strategies to PrepAre SeveRely CALCified Coronary Lesions: the ISAR-CALC randomised trial.

Cardiovascular outcomes after percutaneous coronary intervention on bifurcation lesions with moderate to severe coronary calcium: A single-center registry study

BACKGROUND

Both target vessel calcification and target vessel bifurcation are associated with worse outcomes following percutaneous coronary intervention (PCI). Whether these entities in combination interact to influence outcomes after PCI of complex coronary disease is not known.

OBJECTIVES

This study evaluated the association of target vessel bifurcation and target vessel calcification, alone and in combination, with adverse events following PCI.

METHODS

Registry data from 21,165 patients who underwent PCI with drug-eluting stents (DES) between January 2009 and December 2017 were analyzed. Patients were divided into four groups according to the presence or absence of target vessel bifurcation and presence of none/mild or moderate/severe target vessel calcification on angiography. Associations between lesion groups and 1 year major adverse cardiac events (MACE) were examined using Cox regression analysis.

RESULTS

At 1 year, unadjusted rates of MACE, death, myocardial infarction (MI), as well as stent thrombosis were highest in the group with both bifurcation lesion and moderate/severe calcification. After adjusting for confounders such as age, renal disease, and smoking, hazard ratios for MACE were 1.14 (95%CI 0.99-1.33) for bifurcation with none/mild calcification, 1.21 (95%CI 1.06-1.38) for no bifurcation and moderate/severe calcification, and 1.37 (95%CI 1.14-1.64) for bifurcation and moderate severe calcification, compared to patients with no bifurcation and none/mild calcification.

CONCLUSIONS

The presence of a bifurcating target vessel with moderate/severe calcification is associated with a higher risk of adverse outcomes than either attribute alone. New approaches are needed to improve outcomes in this subset of patients with complex coronary artery disease.

Vascular Lesion-Specific Drug Delivery Systems: JACC State-of-the-Art Review

Drug delivery is central to modern cardiovascular care, where drug-eluting stents, bioresorbable scaffolds, and drug-coated balloons all aim to restore perfusion while inhibiting exuberant healing. The promise and enthusiasm of these devices has in some cases exceeded demonstration of efficacy and even understanding of driving mechanisms. The authors review the means of drug delivery in each device, outlining how the technologies affect vascular behavior. They focus on how drug retention and response are governed by lesion morphology: lipid displacing drug-specific binding sites, calcium inhibiting diffusion, blocking thrombi or promoting luminal washout, and vascular healing steering hyperplastic developments. In this regard, the authors outline the fundamental impact of vascular structure on drug delivery and review the development of contemporary and future devices for coronary and peripheral intervention. They look toward a future where incorporating information on lesion distribution is central to therapeutic success and envision a transition toward lesion-specific treatment for improved interventional outcomes.

Intracoronary Imaging Versus Coronary Angiography to Guide Drug-Coated Balloon Intervention in Coronary Artery Disease: A Propensity-Matched Pilot Study Analysis

Limited data exist about the effect of intracoronary imaging (ICI)-guided drug-coated balloon (DCB) intervention on clinical end points. In all, 1157 patients with coronary artery disease treated with DCB between December 2014 and December 2017 at Beijing Anzhen Hospital were included in the final analysis in this cohort study. The primary end point was the incidence of target lesion failure (TLF), a composite of cardiac death, target vessel myocardial infarction (MI), and target lesion revascularization, and the key secondary end point was the incidence of cardiac death or target vessel MI. The median follow-up for clinical events was 32.0 months (IQR 25.0-40.0). Intracoronary imaging was used in 90 (7.8%) patients. There was no statistically significant difference in TLF (12.2% vs 12.5%, P = .80) between ICI-guided and angiography-guided group. Cardiac death or target vessel MI rates (1.1% vs 3.7%, P = .17) were numerically lower for the ICI-guided cohort. In the propensity score-based analysis, TLF (10.5% vs 16.2%, P = .19) and cardiac death or target vessel MI rates (1.2% vs 2.3%, P = .51) tended to be lower for the ICI-guided cohort. In this observational study, TLF rate tended to decrease in the ICI-guided DCB treatment group compared with angiography-guided procedures. Larger studies are needed.

Vascular Calcification in Chronic Kidney Disease: Diversity in the Vessel Wall

Vascular calcification (VC) is one of the major causes of cardiovascular morbidity and mortality in patients with chronic kidney disease (CKD). VC is a complex process expressing similarity to bone metabolism in onset and progression. VC in CKD is promoted by various factors not limited to hyperphosphatemia, Ca/Pi imbalance, uremic toxins, chronic inflammation, oxidative stress, and activation of multiple signaling pathways in different cell types, including vascular smooth muscle cells (VSMCs), macrophages, and endothelial cells. In the current review, we provide an in-depth analysis of the various kinds of VC, the clinical significance and available therapies, significant contributions from multiple cell types, and the associated cellular and molecular mechanisms for the VC process in the setting of CKD. Thus, we seek to highlight the key factors and cell types driving the pathology of VC in CKD in order to assist in the identification of preventative, diagnostic, and therapeutic strategies for patients burdened with this disease.

The Prognostic Value of a Validated and Automated Intravascular Ultrasound-Derived Calcium Score

Background

Coronary calcification has been linked to cardiovascular events. We developed and validated an algorithm to automatically quantify coronary calcifications on intravascular ultrasound (IVUS). We aimed to assess the prognostic value of an IVUS-calcium score (ICS) on patient-oriented composite endpoint (POCE).

Methods

We included patients that underwent coronary angiography plus pre-procedural IVUS imaging. The ICS was calculated per patient. The primary endpoint was a composite of all-cause mortality, stroke, myocardial infarction, and revascularization (POCE).

Results

In a cohort of 408 patients, median ICS was 85. Both an ICS ≥ 85 and a 100 unit increase in ICS increased the risk of POCE at 6-year follow-up (adjusted hazard ratio (aHR) 1.51, 95%CI 1.05–2.17, p value = 0.026, and aHR 1.21, 95%CI 1.04–1.41, p value = 0.014, respectively).

Conclusions

The ICS, calculated by a validated automated algorithm derived from routine IVUS pullbacks, was strongly associated with the long-term risk of POCE.

Graphical abstract

Supplementary Information

The online version contains supplementary material available at 10.1007/s12265-021-10103-1.

Relative Impact of Clinical Risk Versus Procedural Risk on Clinical Outcomes After Percutaneous Coronary Intervention

BACKGROUND

The clinical outcome after percutaneous coronary intervention (PCI) is affected by various clinical and procedural risk factors. We investigated the relative impact of clinical and procedural risks on clinical outcomes after PCI.

METHODS

A total of 13 172 patients were enrolled from the Grand-DES registry. The population was grouped into tertiles (high-, intermediate-, low-risk) according to the number of prespecified clinical and procedural risk factors, respectively. The primary end point was major adverse cardiac and cerebrovascular events (MACCE) at 3 years post-PCI.

RESULTS

MACCE occurred in 1109 (8.4%) patients during the follow-up period (median duration: 1126 days). Compared with procedural risk, clinical risk showed superior predictive power (area under the curve: 0.678 versus 0.570, P<0.001, for clinical and procedural risks, respectively) and greater magnitude of effect in the multivariate analysis for MACCE (Clinical risk: hazard ratio, 1.953 [95% CI, 1.809-2.109], P<0.001; procedural risk: hazard ratio, 1.240 [95% CI, 1.154-1.331], P<0.001). In subgroup analyses within each clinical risk tertile, procedural risk had no significant impact on MACCE in the lowest clinical risk tertile. An annual landmark analysis revealed that clinical and procedural risks were both significant predictors of MACCE, which occurred within the first and second year post-PCI. However, for MACCE occurring in the third year post-PCI, only clinical risk but not procedural risk was a significant predictor of events.

CONCLUSIONS

Clinical and procedural risks were both significant predictors for ischemic clinical events in patients undergoing PCI. However, clinical risk had a greater and more prolonged effect on outcomes than procedural risk. Registration: URL: https://www.clinicaltrials.gov. Unique identifier: NCT03507205.

Side branch fractional flow reserve after provisional stenting of calcified bifurcation lesions: The ORBID-FFR study

OBJECTIVES

We examined the incidence of side branch (SB) compromise after provisional stenting of calcified bifurcation lesions treated with rotational atherectomy (RA) or cutting balloon angioplasty (CBA) and the utility of optical coherence tomography (OCT) to detect functionally significant SB stenoses.

BACKGROUND

The comparative impact of RA versus CBA on SB compromise and functional significance remains poorly characterized.

METHODS

Seventy-one consecutive patients with 71 calcified bifurcation lesions with angiographically intermediate SB stenoses were randomized to RA (n = 35) or CBA (n = 36). The primary endpoint was SB compromise defined as SB diameter stenosis ≥70%, SB dissection or thrombolysis in myocardial infarction flow grade < 3 after provisional stenting. Secondary endpoints included SB FFR in noncompromised SBs and its correlation with SB ostium area (SBOA) assessed by three-dimensional OCT.

RESULTS

SB compromise after provisional stenting was observed in 7 (20.0%) lesions that underwent RA and in 9 (25.0%) lesions treated with CBA (p = .62). Mean SB FFR was 0.83 ± 0.08 and was similar between the study arms. Functionally significant SB stenosis (FFR ≤ 0.80) was detected in 17(30.9%) angiographically noncompromised SBs. SBOA after stenting was an independent predictor of FFR ≤ 0.80 (OR 0.002, 95% CI: 0.00-0.15, p = .002). The optimal cutoff value for SBOA to predict functionally significant SB stenosis was 0.76 mm² (sensitivity 82%, specificity 89% and area under the curve 0.92, 95% CI: 0.84-0.99).

CONCLUSIONS

The rates of SB compromise and functionally significant stenosis after provisional stenting of calcified bifurcation lesions were similar between two lesion preparation strategies. OCT SBOA can detect SB branches with FFR ≤ 0.80 with high sensitivity and specificity.

Safety and effectiveness of coronary intravascular lithotripsy in eccentric calcified coronary lesions: a patient-level pooled analysis from the Disrupt CAD I and CAD II Studies

BACKGROUND

The aim of this study was to assess the safety and effectiveness of intravascular lithotripsy (IVL) in treating eccentric calcified coronary lesions.

METHODS

Between December 2015 and March 2019, 180 patients were enrolled in the Disrupt CAD I and CAD II studies across 19 sites in 10 countries. Patient-level data were pooled from these two studies (n = 180), within which 47 eccentric lesions (26%) and 133 concentric lesions were identified.

RESULTS

Clinical success, defined as residual stenosis < 50% after stenting and no in-hospital MACE, was similar between the eccentric and concentric cohorts (93.6% vs. 93.2%, p = 1.0). There were no perforations, abrupt closure, slow flow or no reflow events observed in either group, and there were low rates of flow-limiting dissections (Grade D-F: 0% eccentric, 1.7% concentric; p = 0.54). Final acute gain and percent residual stenosis were similar between the two groups. Final residual stenosis of 8.6 ± 9.8% in eccentric and 10.0 ± 9.0% (p = 0.56) in concentric stenosis confirms the significant effect of IVL in calcified coronary lesions.

CONCLUSION

In this first report from a pooled patient-level analysis of coronary IVL from the Disrupt CAD I and CAD II studies, IVL use was associated with consistent improvement in procedural and clinical outcomes in both eccentric and concentric calcified lesions.

Left coronary artery calcification patterns after coronary bypass graft surgery: An in-vivo optical coherence tomography study

OBJECTIVES

We sought to evaluate the severity and patterns of calcifications in the left main coronary artery (LMCA) and proximal segments of left anterior descending coronary artery (LAD) and left circumflex artery (LCX) using optical coherence tomography (OCT) in patients with and without prior coronary artery bypass grafting (CABG).

BACKGROUND

CABG may accelerate upstream calcium development.

METHODS

OCT images (n = 76) of the LMCA bifurcation from either the LAD or LCX in 76 patients with at least one patent left coronary graft, on average 7.0 ± 5.6 years post-CABG, were compared with 148 OCT images in propensity-score-matched non-CABG controls.

RESULTS

Minimum lumen areas in the LMCA, LAD, and LCX in post-CABG patients were smaller than non-CABG controls. Maximum calcium arc and thickness as well as calcium length were greater in the LMCA and LCX, but not in the LAD in post-CABG patients versus non-CABG controls. Calcium located at the carina of a bifurcation, calcified nodules (CN), thin intimal calcium, and lobulated calcium were more prevalent in post-CABG patients. After adjusting for multiple covariates, prior CABG was an independent predictor of calcification at the carina of a bifurcation (odds ratio [OR] 5.77 [95% confidence interval, CI: 1.5-21.6]), thin intimal calcium (4.7 [1.5-14.4]), and the presence of a CN (15.60 [3.2-76.2]).

CONCLUSIONS

Prior CABG is associated with greater amount of calcium in the LMCA and the proximal LCX, as well as higher prevalence of atypical calcium patterns, including CN, thin or lobulated calcium, and calcifications located at the carina of a bifurcation, compared with non-CABG controls.

Novel Micro Crown Orbital Atherectomy for Severe Lesion Calcification: Coronary Orbital Atherectomy System Study (COAST)

Supplemental Digital Content is available in the text.

Percutaneous coronary intervention of severely calcified lesions carries a high risk of adverse events despite the use of contemporary devices. The Classic Crown Orbital Atherectomy System (OAS) was safe and effective for severely calcified lesion preparation in the ORBIT II study (Evaluate the Safety and Efficacy of OAS in Treating Severely Calcified Coronary Lesions) but was not optimized for tight lesions. COAST (Coronary Orbital Atherectomy System Study) evaluated the safety and efficacy of calcified lesion preparation before stent implantation with the Diamondback 360 Micro Crown Coronary OAS, designed for use in tighter lesions.

Management of Calcific Coronary Artery Lesions: Is it Time to Change Our Interventional Therapeutic Approach?

Patients with obstructive coronary lesions with a high calcium content (LHCC) have an exaggerated clinical risk, because the presence of calcification is associated with more extensive coronary atheroma and higher burden of comorbidities. Treatment of LHCC using percutaneous techniques is complex because of an increased risk of incomplete lesion preparation with suboptimal stent deployment and higher rates of acute and chronic stent failure. Rotational atherectomy has been the predominant technology for treatment of high-grade LHCC, but novel devices/technologies have entered clinical practice. It seems likely that combining enhanced intravascular imaging, which allows definition of the patterns of calcification with these new technologies, will herald a change in procedural algorithms for treatment of LHCC. This review provides an overview about LHCC with special focus on existing and emergent technologies. We also provide a proposed procedural algorithm to facilitate optimal use of technology according to specific features of LHCC and coronary anatomy.

Intravascular Imaging to Guide Lithotripsy in Concentric and Eccentric Calcific Coronary Lesions

BACKGROUND

Calcified coronary lesions still represent a challenge for coronary angioplasty, with sub-optimal acute PCI results causing more frequent late stent failure.

PURPOSE

The study aimed at the evaluation of the immediate procedural outcome in a real-world consecutive population of a selective use of lithotripsy based on the intravascular imaging assessment with IVUS or OCT.

METHODS AND RESULTS

Thirty-one calcified stenoses (28 patients) out of a total of 455 lesions (370 patients) treated between November 2018 and May 2019 received IVL under intravascular imaging guidance. The majority of the IVL lesions had angiographically severe calcifications and were selected after intravascular imaging. A smaller group was identified by poor expansion after high-pressure balloon dilatation, in one case despite preliminary small burr Rotablation. After IVL, when OCT was performed calcium fractures were observed in 71% of cases. After OCT/IVUS guided stent optimization a satisfactory lumen enlargement (minimal stent area 7.09 ± 2.77 mm²) was observed with good stent expansion (residual area stenosis<20% in 29 lesions, 93.5%) Peri-procedural complications were limited to one dissection at the distal edge requiring an additional stent and 3 peri-procedural myocardial infarctions. There were no periprocedural coronary perforations or pericardial effusions, and no in-hospital or 30 days stent thrombosis. When patients were divided into two subgroups according to a calcium arc ≤180° (Group A: 10 lesions, calcium arc 140 ± 24°; Group B: 21 lesions, calcium arc 289 ± 53°), at OCT Group B presented also a higher number of calcium fractures post IVL than group A (group A: 38% vs group B: 92%, p = 0.03). The in-stent minimum lumen diameter (MSD), the in stent minimal lumen area (MSA) and the acute gain, however, were similar between the two groups (acute gain group A: 1.22 ± 0.29 mm; group B: 1.31 ± 0.52 mm, p = 0.63).

CONCLUSIONS

A standardized algorithm applying intravascular imaging guidance of IVL facilitated second generation DES expansion delivers excellent immediate lumen expansion and patient outcome, both in concentric and eccentric calcifications.

Three contemporary thin-strut drug-eluting stents implanted in severely calcified coronary lesions of participants in a randomized all-comers trial

OBJECTIVE

The objective was to assess the 2-year clinical performance of three drug-eluting stents in all-comer patients with severely calcified coronary lesions.

BACKGROUND

Severe lesion calcification increases cardiovascular event risk after coronary stenting, but there is a lack of data on the clinical outcome of all-comers with severely calcified lesions who were treated with more recently introduced drug-eluting stents.

METHODS

The BIO-RESORT trial (clinicaltrials.gov: NCT01674803) randomly assigned 3,514 all-comer patients to biodegradable polymer Synergy everolimus-eluting stents (EES) or Orsiro sirolimus-eluting stents (SES), versus durable polymer Resolute Integrity zotarolimus-eluting stents (ZES). In a post hoc analysis, we assessed 783 patients (22.3%) with at least one severely calcified target lesion.

RESULTS

At 2-year follow-up (available in 99% of patients), the main composite endpoint target vessel failure occurred in 19/252 (7.6%) of the EES and in 33/265 (12.6%) of the ZES-treated patients (p = .07). Target vessel failure occurred in 24/266 (9.1%) of the SES-treated patients (vs. ZES: p = .21). There was a difference in target vessel revascularization, which was required in EES in 6/252 (2.4%) patients and in ZES in 20/265 (7.7%) patients (p = .01); the target vessel revascularization rate in SES was 9/266 (3.4%, vs. ZES: p = .04). Multivariate analysis showed that implantation of EES, but not SES, was independently associated with lower target vessel revascularization rates than in ZES.

CONCLUSIONS

In BIO-RESORT participants with severely calcified target lesions, treatment with EES was associated with a lower 2-year target vessel revascularization rate than treatment with ZES.