Intravascular Ultrasound-Derived Calcium Score to Predict Stent Expansion in Severely Calcified Lesions

Role and Value of Intravascular Ultrasound in the End-Stage Renal Disease Population: A Narrative Review

Vascular access for hemodialysis is the lifeline for patients with end-stage renal disease (ESRD); therefore, maintenance of the vascular access is of the utmost importance. The dialysis circuit can be complicated by stenosis or thrombosis. In particular, central venous stenosis is frequently encountered in the vascular access of patients with ESRD, and this complication may require endovascular management. Conventional catheter-based venography may be inadequate for identifying dynamic forms of extrinsic compression and intravascular webs associated with these lesions. For these types of access complications, balloon angioplasty remains the first-line intervention, with stenting reserved for selected scenarios. Accurate assessment of the venous configuration is therefore important to ensure an adequate treatment response. Intravascular ultrasound (IVUS) has been shown to be beneficial in lower extremity venous interventions. The use of IVUS in dialysis access interventions is currently limited but may be indicated in selected challenging clinical situations. In this article, we discuss the potential uses of IVUS in the ESRD population based on our institutional experience and on the current literature.

Assessment of Cutting-Balloon Angioplasty with Novel Bioabsorbable Polymer-Coated Everolimus-Eluting Stent in Treating Calcified Coronary Lesions Guided by Intravascular Ultrasound (CUPID Trial): study design and protocol

BACKGROUND

Various devices and techniques have been used for plaque modification in the treatment of severe coronary artery calcification. This prospective, multicenter, randomized, open-label study aims to evaluate the safety and efficacy of cutting balloon angioplasty using a novel bioabsorbable polymer-coated everolimus-eluting coronary stent for treating various degrees of calcified coronary lesions.

METHODS

We outline the trial design aimed at assessing whether the cutting balloon (Wolverine™) is non-inferior to the non-compliant balloon in treating patients with calcified lesions, encompassing both de novo and in-stent restenosis (ISR) lesions. We aim to enroll 250 patients who have undergone bioabsorbable polymer-coated everolimus-eluting coronary stent (Synergy™) implantation. The primary endpoint is the minimal stent cross-sectional area at the calcium site as determined by intravascular ultrasonography. The secondary endpoints include major adverse cardiac events and target lesion revascularization at 12 months, alongside procedural convenience and operator-centric parameters, such as the number of balloons used, procedure time, and total contrast medium volume used.

DISCUSSION

In this study, we will evaluate the efficacy and safety of Wolverine™ and non-compliant balloon in patients with calcified coronary lesions and provide a rationale for which type of balloons will optimally modify calcium lesions. In addition, we will attempt to expand the indications of the cutting balloon for treating mild-to-severe calcified coronary lesions. As the scope of insurance coverage for cutting balloons remains limited in some countries, this study may provide evidence for extending insurance coverage to the treatment of de novo calcified and ISR lesions.

TRIAL REGISTRATION

ClinicalTrials.gov NCT06177808. Registered on January 1, 2024.

Rotational, orbital atherectomy and intravascular lithotripsy for coronary calcified nodules: insights from optical coherence tomography

BACKGROUND

The optimal treatment strategy for coronary calcified nodules (CN) remains uncertain. We aimed to evaluate the efficacy and safety of different calcium modification strategies, including rotational atherectomy (RA), orbital atherectomy (OA), and intravascular lithotripsy (IVL) for managing CN with optical coherence tomography (OCT) guidance.

METHODS

Consecutive patients undergoing OCT-guided percutaneous coronary intervention (PCI) for severely calcified lesions using RA, OA, or IVL between January 2017 and December 2022 were included. Primary endpoint was minimum stent area (MSA) post-PCI. Secondary endpoints included MSA at CN site and 1-year target vessel failure (TVF), defined as a composite of cardiac death, target-vessel myocardial infarction, or target vessel revascularization.

RESULTS

Among 154 patients and 158 lesions, CN was identified in 54 lesions (34.2%) and managed with RA (39%, n = 21), OA (33%, n = 18), or IVL (28%, n = 15). The IVL group exhibited a larger minimal lumen diameter, maximum calcium arc, and maximum calcium thickness. Post-PCI OCT demonstrated comparable MSA (RA: 6.23 ± 0.34 mm², OA: 5.75 ± 0.39 mm², IVL: 6.24 ± 0.46 mm²; p = 0.62) and MSA at CN site (7.17 ± 0.43 mm², 6.46 ± 0.49 mm², 7.86 ± 0.56 mm², respectively; p = 0.55) after adjusting for morphologic factors. The incidence of TVF at 1 year was similar among the group (RA: 19.0%, OA: 22.2%, IVL: 13.3%, p = 0.81).

CONCLUSIONS

In patients undergoing PCI for CN, similar procedural and clinical outcomes can be achieved using RA, OA, or IVL. These findings warrant further investigation in larger, prospective trials.

Safety, efficacy, and optical coherence tomography insights into intravascular lithotripsy for the modification of non-eruptive calcified nodules: A prospective observational study

BACKGROUND

Non-eruptive calcium nodules (CNs) are commonly seen in heavily calcified coronary artery disease. They are the most difficult subset for modification, and may result in stent damage, malapposition and under-expansion. There are only limited options available for non-eruptive CN modification. Intravascular lithotripsy (IVL) is being explored as a potentially safe and effective modality in these lesions.

AIMS

This study aimed to investigate the safety and efficacy of the use of IVL for the modification of non-eruptive CNs. The study also explored the OCT features of calcium nodule modification by IVL.

METHODS

This is a single-center, prospective, observational study in which patients with angiographic heavy calcification and non-eruptive CN on OCT and undergoing PCI were enrolled. The primary safety endpoint was freedom from perforation, no-reflow/slow flow, flow-limiting dissection after IVL therapy, and major adverse cardiac events (MACE) during hospitalization and at 30 days. MACE was defined as a composite of cardiac death, myocardial infarction (MI), and ischemia-driven target lesion revascularization (TLR). The primary efficacy endpoint was procedural success, defined as residual diameter stenosis of <30% on angiography and stent expansion of more than 80% as assessed by OCT.

RESULTS

A total of 21 patients with 54 non-eruptive CNs undergoing PCI were prospectively enrolled in the study. Before IVL, OCT revealed a mean calcium score of 3.7 ± 0.5 and a mean MLA at CN of 3.9 ± 2.1 mm2. Following IVL, OCT revealed calcium fractures in 40 out of 54 (74.1%) CNs with an average of 1.05 ± 0.72 fractures per CN. Fractures were predominantly observed at the base of the CN (80%). Post IVL, the mean MLA at CN increased to 4.9 ± 2.3 mm2. After PCI, the mean MSA at the CN was 7.9 ± 2.5 mm2. Optimal stent expansion (stent expansion >80%) at the CN was achieved in 85.71% of patients. All patients remained free from MACE during hospitalization and at the 30-day follow-up. At 1-year follow-up, all-cause death had occurred in 3 (14.3%) patients.

CONCLUSIONS

This single-arm study demonstrated the safety, efficacy, and utility of the IVL in a subset of patients with non-eruptive calcified nodules. In this study, minimal procedural complications, excellent lesion modifications, and favorable 30-day and 1-year outcomes were observed.

Advances in Technology and Technique in Percutaneous Coronary Intervention: A Clinical Review

Percutaneous coronary intervention (PCI) has become the standard procedure for patients with angina and acute coronary syndrome. From the perspective of technology and technique, PCI has advanced over the last four decades, resulting in considerably improved clinical outcomes in patients with coronary artery disease in the current era. In this review article, we summarize recent advances, promising technologies, and areas for research in the field of PCI.

Evaluation of balloon and self-expandable stents for common femoral artery stenosis

BACKGROUND

Endovascular treatment of the common femoral artery (CFA) and its bifurcation is currently recommended for patients with hostile groin (prior femoral bifurcation open surgery, history of radiotherapy) or severe comorbidities (advanced age, frailty, obesity). Preliminary results have shown favorable outcomes. Among the different endovascular techniques (atherectomy, intravascular lithotripsy, plain balloon angioplasty, drug-coated balloon angioplasty, stenting), stents are mainly used but the best type of stent to use is still debated. The aim of this study was to assess the value of balloon-expandable stents (BES) and self-expandable stents (SES) for stenosis of the femoral bifurcation.

METHODS

Consecutive patients with stenosis of the CFA and its bifurcation were included from 2016 to 2022. Demographic data, the type of stent used, procedural data, and angiographic variables were collected. Groups were defined according to the type of stent implanted. Primary patency was defined as a binary end point based on a duplex ultrasound peak systolic velocity ratio of ≤2.4 as assessed by duplex ultrasound examination, in the absence of clinically driven target lesion revascularization (TLR) or bypass of the target lesion. Secondary outcomes were clinical sustained improvement, freedom from TLR at 12 months, mean ankle-brachial index improvement, primary-assisted patency, and secondary patency.

RESULTS

A total of 90 procedures conducted in 77 patients were included in this study, 26 in the SES group and 64 in the BES group. The most common symptomatology according to the Rutherford classification was class 2, 3, and 4 (28%, 48%, and 8%, respectively). The type of lesions in the CFA, assessed using the Azema classification, were comparable between both groups (SES/BES group type 2: 31%/27%; type 3: 54%/62%). At 12 months, the primary patency rates for SES and BES were 88% (26/26 patients) and 72% (58/64 patients) (P = .10). At 12 months, freedom from TLR rates for SES and BES were 97% vs 81%, respectively (P = .13).

CONCLUSIONS

SES for CFA stenosis show a trend toward better patency and freedom from TLR rates at 12 months. However, controlled studies are warranted to further investigate the significance of this trend.

Widespread Use of Imaging-Guided PCI in Asia: Time for Extended Application

In recent years, a wealth of clinical data has emerged regarding intravascular imaging involving either intravascular ultrasound or optical coherence tomography. This surge in data has propelled the adoption of intravascular imaging-guided percutaneous coronary intervention (PCI) in daily clinical practice. The findings of current randomized clinical trials regarding imaging guidance have lent strong support to the benefits of intravascular imaging-guided PCI. This holds especially true for the diagnosis and treatment of complex lesions, such as left main disease, diffuse long lesions, chronic total occlusion, severely calcified lesions, bifurcations, and in-stent restenosis, as well as in high-risk patients such as those with acute myocardial infarction or chronic kidney disease. During intravascular imaging-guided PCI, operators attempt to achieve stent optimization for maximized benefits of imaging guidance. This paper provides a comprehensive review on the updated clinical data of intravascular imaging-guided PCI and intravascular ultrasound/optical coherence tomography-derived stent optimization criteria.

Calcified coronary lesions: Imaging, prognosis, preparation and treatment state of the art review

Calcific coronary artery stenosis is a complex disease associated with adverse outcomes and suboptimal percutaneous treatment. Calcium plaque modification has emerged as a key strategy to tackle the issues that accompany calcific stenosis - namely reduced device deliverability, unpredictable lesion characteristics, and difficult dilatation. Atherectomy has traditionally been the treatment modality of choice for heavily calcified coronary stenoses. Contemporary technologies have emerged to aid with planning, preparation, and treatment of calcified coronary stenosis in an attempt to improve procedural success and long-term outcomes. In this State Of The Art Review, we synthesize the body of data surrounding the diagnosis, imaging, and treatment of calcific coronary disease, with a focus on i) intravascular imaging, ii) calcific lesion preparation, iii) treatment modalities including atherectomy, and iv) updated treatment algorithms for the management of calcified coronary stenosis.

Intracoronary imaging guidance of percutaneous coronary interventions: how and when to apply validated metrics to improve the outcome

Percutaneous coronary intervention (PCI) is still burdened by a substantial number of complications despite constant technological advances, including the advent of intracoronary imaging (ICI) techniques. ICI modalities have been instrumental for the understanding the mechanism of PCI failure. Thanks to the ability to detail the pre-intervention coronary anatomy and identify the features indicative of sub-optimal stent deployment, ICI techniques can be utilised to improve coronary interventions in different clinical scenarios. More recently large randomized clinical trials on ICI guidance confirmed the clinical effectiveness of this approach especially in complex high-risk interventions.

Impella Versus Non-Impella for Nonemergent High-Risk Percutaneous Coronary Intervention

The benefit of mechanical circulatory support with Impella (Abiomed, Inc., Danvers, Massachusetts) for high-risk percutaneous coronary intervention (HR-PCI) is uncertain. PROTECT III registry data showed improved outcomes with Impella compared with historical data (PROTECT II) but lack a direct comparison with the HR-PCI cohort without Impella support. We retrospectively identified patients meeting the PROTECT III inclusion criteria for HR-PCI and compared this group (non-Impella cohort [NonIMP]) with the outcomes data from the PROTECT III registry (Impella cohort). Baseline differences were balanced using inverse propensity weighting. The coprimary outcome was major adverse cardiac events (MACE) in-hospital and at 90 days. A total of 283 patients at great risk did not receive Impella support; 200 patients had 90-day event ascertainment and were included in the inverse propensity weighting analysis and compared with 504 patients in the Impella cohort group. After calibration, few residual differences remained between groups. The primary outcome was not different in-hospital (3.0% vs 4.8%, p = 0.403) but less in NonIMP at 90 days (7.5% vs 13.8%, p = 0.033). Periprocedural vascular complications, bleeding, and transfusion rate did not differ between groups; however, acute kidney injury occurred more frequently in the NonIMP group (10.5% vs 5.4%, p = 0.023). In conclusion, under identical HR-PCI inclusion criteria for Impella use in PROTECT III, an institutional non-Impella-supported HR-PCI cohort showed similar MACE in-hospital but fewer MACE at 90 days, whereas there was no signal for periprocedural harm with Impella use. These results do not support routine usage of Impella for patients with HR-PCI.

Intravascular imaging-guided percutaneous coronary intervention for heavily calcified coronary lesions: a systematic review and meta-analysis

Although multiple randomized clinical trials (RCTs) have shown that intravascular imaging (IVI)-guided percutaneous coronary intervention (PCI) is associated with improved clinical outcomes compared with angiography-guided PCI, its benefits specifically in calcified coronary lesions is unclear due to the small number of patients included in individual trials. We performed a meta-analysis of RCTs to investigate benefits of IVI-guided PCI compared with angiography-guided PCI in heavily calcified coronary lesions. The primary endpoint was major adverse cardiac events (MACE), a composite of cardiac death, target-vessel or target-lesion myocardial infarction, and target-vessel or target lesion revascularization. Pooled odds ratios (OR) and 95% confidence intervals (CI) were calculated by using a random-effects meta-analysis based on the restricted maximum likelihood method. A search PubMed, EMBASE, and Cochrane Library from their inception to January 2024 identified 4 trials that randomized 1319 patients with angiographically moderate or severe or severe coronary calcification to IVI-guided (n = 702) vs. angiography-guided PCI (n = 617). IVI-guided PCI resulted in a significantly lower odds of MACE (OR 0.57, 95% CI 0.40-0.80) compared with angiography-guided PCI at a weighted median follow-up duration of 27.3 months. There was no evidence of heterogeneity among the studies (I2 = 0.0%), and included trials were judged to be low risk of bias. Compared with angiography-guided PCI, IVI-guided PCI was associated with a significantly lower MACE in angiographically heavily calcified coronary lesions.

The Unique Role of Intravascular Lithotripsy (IVL) in Debulking the Nodular Calcium in Left Main Coronary Artery Bifurcation

Nodular calcium poses a great challenge during coronary intervention. The presence of nodular calcium is associated with poor post-procedural outcomes. Without debulking the nodular calcium, it is extremely difficult to pass the coronary hardwires including the balloons and drug-eluting stents across the lesion. Application of high atmospheric pressure during balloon inflation in the presence of nodular calcium leads to vessel perforation which is a catastrophe during coronary intervention. We report a rare case of nodular calcium in the left main coronary artery bifurcation which was successfully cracked with pulses of intravascular lithotripsy in a 75-year-old male with old anterior wall myocardial infarction. Although rotablation and orbital arthrectomy have a role in modifying calcium nodules in coronary arteries, intravascular lithotripsy was also successful in debulking the nodular calcium in the left main coronary artery bifurcation.

The Unique Role of Cutting Balloon Angioplasty in Debulking Multiple Nodular Calcium in Osteoproximal and Mid-left Anterior Descending Coronary Artery

We report a rare case of multiple nodular calcium in the left anterior descending coronary artery in an octogenarian presenting with unstable angina. Dilatation with the noncompliant and scoring balloon could not yield the nodular calcium and it was only the cutting balloon that could yield the nodular calcium and successful coronary angioplasty could be accomplished with good angiographic results with distal Thrombolysis in Myocardial Infarction (III) flow. This case demonstrates the unique role of cutting balloons in the angioplasty of coronary lesions with multiple nodular calcium.

Advanced CT Imaging for the Assessment of Calcific Coronary Artery Disease and PCI Planning

Vascular calcification is a hallmark of atherosclerosis and adds considerable challenges for percutaneous coronary intervention (PCI). This review underscores the critical role of coronary computed tomography (CT) angiography in assessing and quantifying vascular calcification for optimal PCI planning. Severe calcification significantly impacts procedural outcomes, necessitating accurate preprocedural evaluation. We describe the potential of coronary CT for calcium assessment and how CT may enhance precision in device selection and procedural strategy. These advancements, along with the ongoing Precise Procedural and PCI Plan study, represent a transformative shift toward personalized PCI interventions, ultimately improving patient outcomes in the challenging landscape of calcified coronary lesions.

SCAI Expert Consensus Statement on the Management of Calcified Coronary Lesions

The prevalence of calcification in obstructive coronary artery disease is on the rise. Percutaneous coronary intervention of these calcified lesions is associated with increased short-term and long-term risks. To optimize percutaneous coronary intervention results, there is an expanding array of treatment modalities geared toward calcium modification prior to stent implantation. The Society for Cardiovascular Angiography and Interventions, herein, puts forth an expert consensus document regarding methods to identify types of calcified coronary lesions, a central algorithm to help guide use of the various calcium modification strategies, tips for when using each treatment modality, and a look at future studies and trials for treating this challenging lesion subset.

Review of intravascular lithotripsy for treating coronary, peripheral artery, and valve calcifications

Management of intracoronary calcium (ICC) continues to be a challenge for interventional cardiologists. There have been significant advances in calcium treatment devices. However, there still exists a knowledge gap regarding which devices to choose for the treatment of ICC. The purpose of this manuscript is to review the principles of intravascular lithotripsy (IVL) and clinical data. The technique of IVL will then be compared to alternative calcium treatment devices. Clinical data will be reviewed concerning the treatment of coronary, peripheral artery and valvular calcifications. Controversies to be discussed include how to incorporate IVL into your practice, what is the best approach for treating calcium subtypes, how to approach under-expanded stents, what is the ideal technique for performing IVL, how safe is IVL, whether imaging adds value when performing IVL, and how IVL fits into a treatment program for peripheral arteries and calcified valves.

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.

A large post-stenting intramural hematoma in the left anterior descending artery caused by a small intimal calcium spur; should we respect the calcium shape?

Coronary heavy calcification (HC) poses a sturdy challenge to percutaneous coronary intervention (PCI). Scores considering calcification length, thickness, or circumferential extent, are widely accepted to dictate upfront calcium modification to improve PCI outcomes. Although often marginalized, calcification shape (morphology) may require consideration during procedure planning in selected cases. This case demonstrates how a focal but spur-shaped calcification led to a massive proximal left anterior descending (LAD) dissecting intramural hematoma.

Coronary intravascular lithotripsy in contemporary practice: challenges and opportunities in coronary intervention

Percutaneous coronary intervention (PCI) of calcified coronary arteries is associated with poor outcomes. Poorly modified calcified lesion hinders the stent delivery, disrupts drug-carrying polymer, impairs drug elution kinetics and results in under-expanded stent (UES). UES is the most common cause of acute stent thrombosis and in-stent restenosis after PCI of calcified lesions. Angiography has poor sensitivity for recognition and quantification of coronary calcium, thereby mandating the use of intravascular imaging. Intravascular imaging, like intravascular ultrasound and optical coherence tomography, has the potential to accurately identify and quantify the coronary calcium and to guide appropriate modification device before stent placement. Available options for the modification of calcified plaque include modified balloons (cutting balloon, scoring balloon and high-pressure balloon), atherectomy devices (rotational atherectomy and orbital atherectomy) and laser atherectomy. Coronary intravascular lithotripsy (IVL) is the newest addition to the tool box for calcified plaque modification. It produces the acoustic shockwaves, which interact with the coronary calcium to cause multiplanar fractures. These calcium fractures increase the vessel compliance and result in desirable minimum stent areas. Coronary IVL has established its safety and efficacy for calcified lesion in series of Disrupt CAD trials. Its advantages over atherectomy devices include ease of use on workhorse wire, ability to modify deep calcium, no debris embolization causing slow flow or no-flow and minimal thermal injury. It is showing promising results in modification of difficult calcified lesion subsets such as calcified nodule, calcified left main bifurcation lesions and chronic total occlusion. In this review, authors will summarize the mechanism of action for IVL, its role in contemporary practice, evidence available for its use, its advantages over atherectomy devices and its imaging insight in different calcified lesion scenarios.

Impact of calcium on the procedural techniques and outcomes of chronic total occlusion percutaneous coronary intervention

BACKGROUND

Coronary calcification is common and increases the difficulty of chronic total occlusion (CTO) percutaneous coronary intervention (PCI).

METHODS

We examined the impact of calcium on procedural outcomes of 13,079 CTO PCIs performed in 12,799 patients at 46 US and non-US centers between 2012 and 2023.

RESULTS

Moderate or severe calcification was present in 46.6% of CTO lesions. Patients whose lesions were calcified were older and more likely to have had prior coronary artery bypass graft surgery. Calcified lesions were more complex with higher J-CTO score (3.0 ± 1.1 vs. 1.9 ± 1.2; p < 0.001) and lower technical (83.0% vs. 89.9%; p < 0.001) and procedural (81.0% vs. 89.1%; p < 0.001) success rates compared with mildly calcified or non-calcified CTO lesions. The retrograde approach was more commonly used among cases with moderate/severe calcification (40.3% vs. 23.5%; p < 0.001). Balloon angioplasty (76.6%) was the most common lesion preparation technique for calcified lesions, followed by rotational atherectomy (7.3%), laser atherectomy (3.4%) and, intravascular lithotripsy (3.4%). The incidence of major adverse cardiovascular events (MACE) was higher in cases with moderate or severe calcification (3.0% vs. 1.2%; p < 0.001), as was the incidence of perforation (6.5% vs. 3.4%; p < 0.001). On multivariable analysis, the presence of moderate/severe calcification was independently associated with lower technical success (odds ratio, OR = 0.73, 95% CI: 0.63-0.84) and higher MACE (OR = 2.33, 95% CI: 1.66-3.27).

CONCLUSIONS

Moderate/severe calcification was present in nearly half of CTO lesions, and was associated with higher utilization of the retrograde approach, lower technical and procedural success rates, and higher incidence of in-hospital MACE.

The estimation of coronary artery calcium thickness by computed tomography angiography based on optical coherence tomography measurements

Optical coherence tomography (OCT) is recommended to be the most appropriate modality in assessing calcium thickness, however, it has limitations associated with infrared attenuation. Although coronary computed tomography angiography (CCTA) detects calcification, it has low resolution and hence not recommended to measure the calcium size. The aim of this study was to devise a simple algorithm to estimate calcium thickness based on the CCTA image. A total of 68 patients who had CCTA for suspected coronary artery disease and subsequently went on to have OCT were included in the study. 238 lesions of them divided into derivation and validation dataset at 2:1 ratio (47 patients with 159 lesions and 21 with 79, respectively) were analyzed. A new method was developed to estimate calcium thickness from the maximum CT density within the calcification and compared with calcium thickness measured by OCT. Maximum Calcium density and measured calcium-border CT density had a good correlation with a linear equation of y = 0.58x + 201 (r = 0.892, 95% CI 0.855-0.919, p < 0.001). The estimated calcium thickness derived from this equation showed strong agreement with measured calcium thickness in validation and derivation dataset (r2 = 0.481 and 0.527, 95% CI 0.609-0.842 and 0.497-0.782, p < 0.001 in both, respectively), more accurate than the estimation by full width at half maximum and inflection point method. In conclusion, this novel method provided the estimation of calcium thickness more accurately than conventional methods.

Intravascular lithotripsy compared to rotational atherectomy for the treatment of calcified distal left main coronary artery disease: A single center experience

BACKGROUND

The safety and efficacy of intravascular lithotripsy (IVL) for the treatment of calcified distal left main (LM) disease remains unclear, especially compared to rotational atherectomy (RA).

METHODS

We retrospectively analyzed the baseline clinical, angiographic, intravascular ultrasound (IVUS) characteristics and procedural outcomes of 107 patients who underwent distal LM percutaneous coronary intervention (PCI) with IVL (with or without adjunct atherectomy) versus RA alone for plaque modification before stenting at a single center between 2020 and 2022.

RESULTS

A total of 50 patients underwent calcium modification with IVL with or without adjunct atherectomy and 57 with RA only. The mean age was 73 years and with a high prevalence of diabetes (58.9%), chronic kidney disease (42.1%), prior revascularization (coronary artery bypass graft surgery [36.4%] or prior PCI [32.7%]). Acute coronary syndrome was the primary indication for PCI in over 50% of the patients in both groups. Medina 1-1-1 LM bifurcation disease was identified in 64% and 60% of the IVL and RA groups (p = 0.64) respectively. Final minimum stent area in distal LM (>8.2 mm2 ), ostial LAD (>6.3 mm2 ) and ostial LCX (>5.0 mm2 ) were achieved in 96%, 85% and 89% of cases treated with IVL respectively and 93%, 93% and 100% of cases treated with RA respectively (LM p = 1.00; LAD p = 0.62; LCX; p = 1.00 for difference between the two groups). Procedural success (technical success without in-hospital major adverse events) was achieved in 98% of the IVL group and 86% of the RA-only group (p = 0.04). There were eight procedural complications (flow-limiting dissection, perforation, or slow/no-reflow) in the RA group compared to four in the IVL group (NS), and one patient in the RA required salvaged mechanical support compared to none in the IVL group.

CONCLUSION

Plaque modification with coronary IVL appears to be efficacious and safe for the treatment of severely calcified distal LM lesions compared to RA only. Larger randomized studies are needed to confirm these findings.

Near-infrared spectroscopy-intravascular ultrasound to improve assessment of coronary artery disease severity in patients referred for transcatheter aortic valve implantation (The IMPACTavi registry): Design and rationale

BACKGROUND

Transcatheter aortic valve implantation (TAVI) was established as a standard treatment for high-operative risk patients with severe aortic stenosis (AS). Although coronary artery disease (CAD) often coexists with AS, clinical and angiographic evaluations of stenosis severity are unreliable in this specific setting. To provide precise risk stratification of coronary lesions, combined near-infrared spectroscopy and intravascular ultrasound (NIRS-IVUS) was developed to integrate morphological and molecular information on plaque composition. However, there is a lack of evidence on the association between NIRS-IVUS derived findings such as maximum 4mm lipid core burden index (maxLCBI4mm) and clinical outcomes in AS patients undergoing TAVI. This registry aims to assess feasibility and safety of NIRS-IVUS imaging in the setting of routine pre-TAVI coronary angiography to improve assessment of CAD severity.

METHODS

The registry is designed as a non-randomized, prospective, observational, multicenter cohort registry. Patients referred for TAVI with angiographic evidence of CAD receive NIRS-IVUS imaging and are followed up to 24 months. Enrolled patients are classified as NIRS-IVUS positive and NIRS-IVUS negative, respectively, based on their maxLCBI4mm to compare their clinical outcomes. The primary endpoint of the registry is major adverse cardiovascular events over a 24-month follow-up period.

CONCLUSIONS

Identification of patients likely or unlikely to benefit from revascularization prior to TAVI represents an important unmet clinical need. This registry is designed to investigate whether NIRS-IVUS-derived atherosclerotic plaque characteristics can identify patients and lesions at risk for future adverse cardiovascular events after TAVI, in order to refine interventional decision-making in this challenging patient population.

Plaque morphology and distribution in patients with and without myocardial bridge - an intravascular ultrasound study

BACKGROUND

Myocardial bridging (MB) is a common congenital cardiovascular anomaly. There are reported associations of MB with different clinical presentations like effort angina, acute coronary syndromes (ACS) and sudden cardiac death. Acceleration of atherosclerosis in proximal vessel is reported in patients with MB, while bridged segments are reported to be free of atherosclerosis.

METHODS

We assessed patients who underwent intravascular ultrasound (IVUS) guided percutaneous intervention (PCI) of left anterior descending (LAD) artery. Plaque characteristics derived from IVUS analysis were compared between those who displayed myocardial bridge versus those who did not harbour the anomaly.

RESULTS

One hundred and forty-seven (147) patients underwent IVUS guided PCI. Incidence of MB was 44/147 (29.9%). Mean age of patients who had MB {+} was higher (62.1 ± 10.3 vs. 57.8 ± 11.2 (p = .03). 142/147 (96.6%) patients presented with ACS. ST elevation myocardial infarction (STEMI) was the most common presenting diagnosis (110/147 to 74.8%). There were no differences in qualitative plaque characteristics - attenuated plaque, calcification or calcium score between two groups. Plaque burden and length of the lesion in the proximal vessel were not different. Among patients with MB {+}, atheromatous extension to segments underlying the bridge was seen in 31/44 (70.5%) cases.

CONCLUSIONS

In a series of patients who presented with advanced clinical atherosclerosis, plaque characteristics were not different in patients who harboured myocardial bridge vs. those who did not have the anomaly. Atheromatous involvement was seen extending into bridged segment contrary to previous reports.

State-of-art review: intravascular imaging in percutaneous coronary interventions

The history of intravascular ultrasound (IVUS) and optical coherence tomography (OCT) reflects the relentless pursuit of innovation in interventional cardiology. These intravascular imaging technologies have played a pivotal role in our understanding of coronary atherosclerosis, vascular pathology, and the interaction of coronary stents with the vessel wall. Two decades of clinical investigations demonstrating the clinical efficacy and safety of intravascular imaging modalities have established these technologies as staples in the contemporary cardiac catheterization lab's toolbox and earning their place in revascularization clinical practice guidelines. In this comprehensive review, we will delve into the historical evolution, mechanisms, and technical aspects of IVUS and OCT. We will discuss the expanding evidence supporting their use in complex percutaneous coronary interventions, emphasizing their crucial roles in optimizing patient outcomes and ensuring procedural success. Furthermore, we will explore the substantial advances that have propelled these imaging modalities to the forefront of contemporary interventional cardiology. Finally, we will survey the latest developments in the field and explore the promising future directions that have the potential to further revolutionize coronary interventions.

Lifetime management of severely calcified coronary lesions: the treatment algorithm focused on the shape of calcification

The concept of lifetime management has not been discussed in the field of percutaneous coronary intervention (PCI), because the durability of drug-eluting stent (DES) is considered to be long enough for most patients. Furthermore, even if in-stent restenosis occurs, the treatment for in-stent restenosis is simple in most cases. On the other hand, the long-term clinical outcomes after DES implantation are worse in severely calcified coronary lesions than in non-calcified lesions. Moreover, the treatment for in-stent calcified restenosis or restenosis due to stent underexpansion is not simple. The concept of lifetime management of severely calcified lesions may be necessary like that of aortic stenosis. Recently, several algorithms have been published in PCI to severely calcified lesions, partly because of the emergence of IVL. These algorithms focus on the selection of cracking and debulking devices for the preparation of stenting. However, the optimal stent expansion does not guarantee the long-term patency, when the target lesion includes calcified nodules. Stent restenosis due to calcified nodules is difficult to manage. In this review article, we propose the algorithm for severely calcified lesions focused on the shape of calcification. We do not need to hesitate stenting when multiple cracks on circumferential calcification are observed by intravascular imaging devices. However, DCB may be an option as final device in some situations, when lifetime management of severely calcified lesions is considered.

Safety and Efficacy of Orbital Atherectomy in the All-Comer Population: Mid-Term Results of the Lower Silesian Orbital Atherectomy Registry (LOAR)

BACKGROUND

Coronary calcifications represent a challenging subset for the interventional cardiologist performing percutaneous coronary intervention (PCI) and are well-established risk factors for adverse outcomes. Adequate plaque modification prior to stent implantation is critical to achieve an optimal outcome following PCI. Recently, a novel orbital atherectomy device has been introduced into clinical practice to modify calcified plaques. We evaluated the mid-term safety and efficacy of OA in a high-risk "all-comers" population.

METHODS

We evaluated 96 consecutive patients with severely calcified coronary lesions who underwent PCI facilitated by the orbital atherectomy device.

RESULTS

In-hospital MACCE was 5.2% without target lesion revascularization. At 6-month follow-up, the MACCE rate was 10.4% with a concomitant TLR rate of 1%.

CONCLUSIONS

Our mid-term data showed good safety and efficacy of orbital atherectomy as a plaque-modifying tool in an all-comers cohort with severely calcified coronary lesions.

Intravascular Lithotripsy for the Treatment of Severely Calcified Coronary Artery Disease: A DISRUPT CAD III Intravascular Ultrasound Substudy

BACKGROUND

Coronary intravascular lithotripsy (IVL) has emerged as a novel technique for the treatment of severely calcified coronary lesions. We evaluated the mechanism and efficacy of IVL in facilitating optimal stent implantation in heavily calcified coronary lesions using intravascular ultrasound (IVUS).

METHODS

Forty-six patients were initially enrolled as a part of the Disrupt CAD III study. Of these, 33 had pre-IVL, 24 had post-IVL, and 44 had post-stent IVUS evaluation. The final analysis was performed on 18 patients who had IVUS images interpretable at all three intervals. The primary endpoint was increase in minimum lumen area (MLA) from pre-IVL to post-IVL treatment to post-stenting.

RESULTS

Pre-IVL, MLA was 2.75 ± 0.84 mm2, percent area stenosis was 67.22 % ± 20.95 % with maximum calcium angle of 266.90° ± 78.30°, confirming severely calcified lesions. After IVL, MLA increased to 4.06 ± 1.41 mm2 (p = 0.0003), percent area stenosis decreased to 54.80 % ± 25.71 % (p = 0.0009), and maximum calcium angle decreased to 239.40° ± 76.73° (p = 0.003). There was a further increase in MLA to 6.84 ± 2.18 mm2 (p < 0.0001) and decrease in percent area stenosis to 30.33 % ± 35.08 % (p < 0.0001) post-stenting with minimum stent area of 6.99 ± 2.14 mm2. The success rate of stent delivery, implantation, and post-stent dilation was 100 % post-IVL.

CONCLUSION

In this first study evaluating the mechanism of IVL using IVUS, the primary endpoint of increase in MLA from pre-IVL to post-IVL treatment to post-stenting was successfully achieved. Our study showed that the use of IVL-assisted percutaneous coronary intervention is associated with improved vessel compliance, facilitating optimal stent implantation in de novo severely calcified lesions.

Combination of Laser Atherectomy and Super High-pressure Non-compliant Balloon to Treat Stent Under-expansion in Cases of Failed Interventional Options

Patients with calcified, fibrotic native coronary vessels with prior suboptimal stenting outcomes are at major risk of stent thrombosis and could face serious consequences if untreated. In cases of multiple layers of under-expanded stents, the risk is multiplied. If conventional balloon post-dilatation is unsuccessful after stent implantation without proper lesion preparation, few interventional options remain. The authors report on a patient with prior numerous right coronary unsuccessful coronary interventions resulting in partially crushed multiple layers of stent material with critical lumen narrowing caused by stent under-expansion. Balloon angioplasty and stent rotational atherectomy (ROTA) had been attempted to overcome stent under-expansion but were unsuccessful. The authors investigated a new combination therapy of laser atherectomy (ELCA) and super high-pressure balloon (OPN non-compliant balloon) to treat single or multiple layers of stent with severe under-expansion due to fibrotic, calcified tissue surrounding the under-expanded stent structure.

Current Management of Highly Calcified Coronary Lesions: An Overview of the Current Status

The amount of coronary calcium strongly correlates with the degree of atherosclerosis and, therefore, with the rate of future cardiac events. Calcified coronary lesions still represent a challenge for interventional cardiologists, bringing not only a higher risk of immediate complications during percutaneous coronary interventions (PCI), but also a higher risk of late stent failure due to under-expansion and/or malapposition, and therefore, have a relevant prognostic impact. Accurate identification of the calcified plaques together with the analysis of their distribution pattern within the vessel wall by intracoronary imaging is important to improve the successful treatment of these lesions. The aim of this review is to guide readers through the assessment of the calcified plaque distribution using intracoronary imaging in order to select the best devices and strategies for plaque debulking and lesion preparation.

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.

Intravascular Ultrasound Guided Intervention in Calcified Coronary Lesions Showed Good Clinical Outcomes during One Year Follow-Up

BACKGROUND

Calcified coronary lesions can cause stent under-expansion, malapposition, and polymer degradation, hence increasing the risk of adverse clinical outcomes. Percutaneous coronary intervention (PCI) guided by intravascular ultrasound (IVUS) has been used regularly to improve outcomes. Our primary aim was to evaluate the clinical efficacy of IVUS-guided PCI in calcified coronary lesions.

METHODS

From August 2018 to December 2021, we prospectively included 300 patients in the CAPIRO study (CAlcified plaque in patients receiving Resolute Onyx®) at three educational hospitals in Jeonbuk Province. We studied 243 patients (265 lesions) who were followed up for over a year. Based on coronary calcification by IVUS analysis, the patient population was categorized into two groups (Group I: non/mild calcification; Group II: moderate/severe calcification (maximum calcium arc >180° and calcium length > 5 mm)). One-to-one Propensity Score Matching was used to match the baseline characteristics. The stent expansion rate was analyzed by recent criteria. The primary clinical outcome was Major Adverse Cardiac Events (MACE), which included Cardiac death, Myocardial Infarction (MI), and Target Lesion Revascularization (TLR).

RESULTS

After follow-up time, the MACE rate in Group I was 1.99%, comparable to Group II's 1.09% (p = 0.594). The components of MACE did not significantly differ between the two groups. Based on absolute MSA or MSA/MVA at MSA site criteria, the stent expansion rate in Group II was lower than that of Group I. Nevertheless, based on recent relative criteria, the stent expansion rate in both groups was comparable.

CONCLUSIONS

After more than a year of follow-up, IVUS-guided PCI in moderate/severe calcification lesions was associated with good clinical outcomes, which was comparable with non/mild calcification lesions. Future studies with a larger sample size and a more extended follow-up period are required to clarify our findings.

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.

The role of invasive and non-invasive imaging technologies and calcium modification therapies in the evaluation and management of coronary artery calcifications

The treatment of coronary artery disease (CAD) has advanced significantly in recent years due to improvements in medical therapy and percutaneous or surgical revascularization. However, a persistent obstacle in the percutaneous management of CAD is coronary artery calcification (CAC), which portends to higher rates of procedural challenges, post-intervention complications, and overall poor prognosis. With the advent of novel multimodality imaging technologies spanning from intravascular ultrasound to optical coherence tomography to coronary computed tomography angiography combined with advances in calcium debulking and modification techniques, CACs are now targets for intervention with growing success. This review will summarize the most recent developments in the diagnosis and characterization of CAC, offer a comparison of the aforementioned imaging technologies including which ones are most suitable for specific clinical presentations, and review the CAC modifying therapies currently available.

Maternal socioeconomic and lifestyle factors and life dissatisfaction associated with a small for gestational age infant. The Survey of Neonates in Pomerania (SNiP)

PURPOSE

The aim is to investigate the associations of the mother's socioeconomic and lifestyle factors and life satisfaction with the delivery of a small for gestational age (SGA) infant.

METHODS

Data from 4598 participants of the population-based birth cohort study Survey of Neonates in Pomerania (SniP) including comprehensive information on pregnancies, mothers, and their offspring in Western Pomerania, Germany were used in this study. The associations were analyzed using linear and logistic regression models.

RESULTS

After logistic regression analysis adjusted for height of the mother, women who delivered SGA infants, had lower education (p < 0.01) and smoked more frequently during pregnancy (p < 0.01) compared with mothers of adequate for gestational age (AGA) neonates. A mother with less than 10 years of education and one who continued smoking during pregnancy had an odds ratio (OR) of 2.23 [95% confidence interval (CI) = 1.44 to 3.46] and 2.68 (95% CI = 2.06-3.49) of having an SGA infant, respectively. There was no association between the employment of the mother (p = 0.28), the monthly income (p = 0.09), the family status (p = 0.80), the number of friendships outside the household that the mother would not wish to relinquish (p = 0.47), the number of people that she could rely on in case of an emergency (p = 0.75), or alcohol consumption prior to (p = 0.14) or during the pregnancy (p = 0.99) with SGA. Finally, women who delivered SGA infants were more frequently dissatisfied with their employment (p = 0.03) and financial status (p < 0.01).

CONCLUSIONS

Women who delivered SGA infants had more associated socioeconomic and lifestyle risk factors and were more frequently dissatisfied with their life conditions than mothers of AGA neonates.

Device indication for calcified coronary lesions based on coronary imaging findings

Performing percutaneous coronary intervention (PCI) for calcified lesions is still a major challenge. Calcified lesions are a cause of inadequate dilatation, leading to poor short- and long-term PCI outcomes. It has been suggested that modification for calcification before stent implantation might improve outcomes by providing adequate dilation. Intravascular lithotripsy (IVL) is available under insurance reimbursement in December 2022 in Japan. IVL is one candidate for a treatment device to modify calcified lesions in addition to atherectomy, such as rotational and orbital atherectomy, and special balloons, such as scoring and cutting balloons. Although the evidence for the indications, of these devices is insufficient, they must be used appropriately in clinical practice. In this report, we propose a method for determining an indication of these devices solely as per the coronary imaging findings with intravascular ultrasound or optical coherent tomography. This consensus document represents the collective opinion of experts on the best current indications and should be changed based on future evidence. However, we believe that it represents the optimal criteria for selecting treatment options in the current situation.

Clinical expert consensus document on rotational atherectomy from the Japanese association of cardiovascular intervention and therapeutics: update 2023

The Task Force on Rotational Atherectomy of the Japanese Association of Cardiovascular Intervention and Therapeutics (CVIT) proposed the expert consensus document to summarize the techniques and evidences regarding rotational atherectomy (RA) in 2020. Because the revascularization strategy to severely calcified lesions is the hottest topic in contemporary percutaneous coronary intervention (PCI), many evidences related to RA have been published since 2020. Latest advancements have been incorporated in this updated expert consensus document.

Safety and efficiency of percutaneous coronary intervention using a standardised optical coherence tomography workflow

BACKGROUND

While intravascular imaging guidance during percutaneous coronary intervention (PCI) improves outcomes, routine intravascular imaging usage remains low, in part due to perceived inefficiency and safety concerns.  Aims: The LightLab (LL) Initiative was designed to evaluate whether implementing a standardised optical coherence tomography (OCT) workflow impacts PCI safety metrics and procedural efficiency.

METHODS

In this multicentre, prospective, observational study, PCI procedural data were collected over 2 years from 45 physicians at 17 US centres. OCT-guided PCI incorporating the LL workflow (N=264), a structured algorithm using routine pre- and post-PCI OCT imaging, was compared with baseline angiography-only PCI (angio) (N=428). Propensity score analysis identified 207 matched procedures. Outcomes included procedure time, radiation exposure, contrast volume, device utilisation, and treatment strategy.

RESULTS

Compared with angiography alone, LL workflow OCT-guided PCI increased the median procedural time by 9 minutes but reduced vessel preparation time (2 min LL workflow vs 3 min angio; p<0.001) and resulted in less unplanned additional treatment (4% LL workflow vs 10% angio; p=0.01). With LL workflow OCT guidance, fewer cineangiography views were needed compared to angiography guidance, leading to decreased radiation exposure (1,133 mGy LL workflow vs 1,269 mGy angio; p=0.02), with no difference in contrast utilisation between groups (p=0.28). Furthermore, LL workflow OCT guidance resulted in fewer predilatation balloons and stents being used, more direct stent placement, and greater stent post-dilatation than angiography-guided PCI.

CONCLUSIONS

The incorporation of a standardised pre- and post-PCI OCT imaging workflow improves procedural efficiency and safety metrics, at a cost of a modestly longer procedure time.

Intravascular Imaging During Percutaneous Coronary Intervention: JACC State-of-the-Art Review

Coronary angiography has historically served as the gold standard for diagnosis of coronary artery disease and guidance of percutaneous coronary intervention (PCI). Adjunctive use of contemporary intravascular imaging (IVI) technologies has emerged as a complement to conventional angiography-to further characterize plaque morphology and optimize the performance of PCI. IVI has utility for preintervention lesion and vessel assessment, periprocedural guidance of lesion preparation and stent deployment, and postintervention assessment of optimal endpoints and exclusion of complications. The role of IVI in reducing major adverse cardiac events in complex lesion subsets is emerging, and further studies evaluating broader use are underway or in development. This paper provides an overview of currently available IVI technologies, reviews data supporting their utilization for PCI guidance and optimization across a variety of lesion subsets, proposes best practices, and advocates for broader use of these technologies as a part of contemporary practice.

Mean density of computed tomography for predicting rotational atherectomy during percutaneous coronary intervention

BACKGROUND

Multi-slice computed tomography (CT) allows noninvasive evaluation of the severity of coronary calcification. However, there has yet to be a definitive parameter based on the cross-sectional CT image for predicting the need for rotational atherectomy (RA). Therefore, we aimed to investigate the mean density of cross-sectional CT images to predict the need for RA during percutaneous coronary intervention (PCI).

METHODS

A total of 154 lesions with moderate to severe calcification detected in coronary angiography were identified in 126 patients who underwent coronary CT prior to PCI for stable angina. PCI with RA was performed for 48 lesions, and the remaining 106 were treated without RA. Multi-slice CT was retrospectively evaluated for its ability to predict the use of RA. We chose the most severely calcified cross-sectional image for each lesion. The mean density within the outer vessel contour, calcium arc quadrant of the cross-sectional CT image, calcium length, calcification remodeling index, and per-lesion coronary artery calcium score was studied.

RESULTS

Receiver-operator characteristic curve analysis revealed 637 Hounsfield units (HU) (area under the curve ​= ​0.98, 95% confidence interval: 0.97-1.00, p ​< ​0.001) as the best mean density cutoff value for predicting RA. Multivariate logistic regression analysis showed that a mean calcium level >637 HU was a strong independent predictor (odds ratio: 32.8, 95% confidence interval: 7.0-153, p ​< ​0.001) for using RA.

CONCLUSIONS

The mean density of the cross-sectional CT image, a simple quantitative parameter, was the strongest predictor of the need for RA during PCI.

Contemporary percutaneous management of coronary calcification: current status and future directions

Severe coronary artery calcification is one of the greatest challenges in attaining success in percutaneous coronary intervention, limiting acute and long-term results. In many cases, plaque preparation is a critical prerequisite for delivery of devices across calcific stenoses and also to achieve adequate luminal dimensions. Recent advances in intracoronary imaging and adjunctive technologies now allow the operator to select the most appropriate strategy in each individual case. In this review, we will revisit the distinct advantages of a complete assessment of coronary artery calcification with imaging and application of appropriate and contemporary plaque modification technologies in achieving durable results in this complex lesion subset.

Contemporary Interventional Approach to Calcified Coronary Artery Disease

Calcific coronary artery disease is an increasingly prevalent entity in the catheterization laboratory which has implications for stenting and expected outcomes. With new interventional techniques and equipment, strategies to favorably modify coronary calcium prior to stenting continue to evolve. This paper sought to review the latest advances in the management of severe coronary artery calcification in the catheterization laboratory and discuss contemporary percutaneous interventional approaches.

An algorithmic approach to balloon undilatable coronary lesions

Balloon undilatable lesions are lesions that have been successfully crossed by both a guidewire and a balloon but cannot be expanded despite multiple high-pressure balloon inflations. Balloon undilatable lesions can be de novo or in-stent. We describe a systematic, algorithmic approach to treat both de novo and in-stent balloon undilatable lesions using various techniques, such as high-pressure balloon inflation, plaque modification balloons, intravascular lithotripsy, very high-pressure balloon inflation, coronary atherectomy, laser coronary angioplasty, and extraplaque lesion crossing. Knowledge of the various techniques can increase the efficiency, success and safety of the procedure.

Interobserver Variability Between Expert, Experienced, and Novice Operator Affects Interpretation of Optical Coherence Tomography and 20 MHz Intravascular Ultrasound Imaging

BACKGROUND

Vessel sizing and calcium detection by intracoronary imaging informs optimal strategy during coronary interventions, but image interpretation and analysis software vary considerably between platforms. We compared the interobserver variability of clinicians with a range of experience in assessing co-registered optical coherence tomography (OCT) and 20 MHz solid state intravascular ultrasound (IVUS) vessel/ lumen geometry and quantitative plaque data.

METHODS

Co-registered OCT and IVUS frames at the minimum lumen area (MLA) and 5 frames at 2 mm intervals upstream and downstream were read blinded by an expert, consultant, interventional fellow and registrar to define vessel and lumen sizes, plaque characteristics (arc of calcium and lipid) and presence of OCT-defined thin-capped fibroatheroma (TCFA).

RESULTS

Overall, 143 paired frames of OCT and IVUS were analysed. Excellent consistency was seen for all OCT measures of vessel/luminal geometry irrespective of experience (all intraclass correlation coefficients (ICC) >0.89). Inexperience compromised ICC for IVUS (lumen area ICC 0.56; vessel size ICC 0.65) and overestimated lumen size compared to expert (p < 0.001). Calcium arc agreement for OCT and IVUS was equally strong for all but the most inexperienced reader (ICC >0.84). OCT lipid arc agreement was moderate for experienced readers but poor for all grades of reader with IVUS (ICC 0.24-0.43). OCT-TCFA agreement was moderate between expert and consultant (κ = 0.55) and poor for less experienced readers.

CONCLUSION

OCT dimensions are minimally affected by observer experience and more consistent than IVUS. Inexperienced readers oversize with IVUS. Calcium arc is dependably assessed by IVUS and OCT by all but the most inexperienced reader.

Rotational atherectomy for chronically and totally occluded coronary lesions: A propensity score-matched outcomes study

Background

Despite advances being made in techniques and devices, certain chronic total occlusion (CTO) lesions remain uncrossable or undilatable. Rotational atherectomy (RA) is usually necessary for such lesions to achieve successful revascularization.

Methods

Information regarding consecutive patients who underwent coronary RA was retrieved from the catheterization laboratory database. Patients who underwent RA for CTO lesion refractory using other conventional devices were recruited, with propensity score-matched cases serving as controls.

Results

A total of 411 patients underwent coronary RA in the study period. Most patients had high-risk features (65.7% had acute coronary syndrome (ACS), 14.1% ischemic cardiomyopathy, and 5.1% cardiogenic shock), while only 20.2% of the patients had stable angina. Among them, 44 patients underwent RA for CTO lesions (CTO group), whereas the propensity score matched controls consist of 37 patients (non-CTO group). The baseline characteristics, high-risk features, coronary artery disease (CAD) vessel numbers, left ventricular function and biochemistry profiles of both groups were the same except for more patients with diabetes (67.6% vs. 45.5%, p = 0.046) in the non-CTO group and more 1.25 mm burr uses in the CTO group. There were no significant differences in acute procedural outcomes or incidence of acute contrast-induced nephropathy (CIN), and no patient demanded emergent CABG or died during the procedure. There was no significant difference in major adverse cardiovascular events (MACE), CV MACE or individual components between the two groups in the hospital, at 30, 90, and 180 days or at 1 year.

Conclusion

In comparison with the propensity risk factor scores-matched controls, there was no difference in procedural complications, acute CIN or clinical outcomes during various stages of RA for CTO lesions. RA for CTO patients was highly efficient and showed safety and outcome profiles similar to those for non-CTO lesions.

[Invasive and non-invasive imaging analysis for calcified coronary artery lesions]

Coronary calcifications are frequently identified within coronary lesions as their incidence increases with age and cardiovascular risk factors. Their location can be superficial or deep, according to different pathological process. In all cases, the presence of calcifications within the vascular wall predicts poor clinical prognosis and unfavorable evolution after percutaneous revascularization. Coronary calcifications can be analyzed by angiography, CT or intracoronary imaging (IVUS or OCT) with variable accuracies. Angiography is the most frequently used method but is not very sensitive (sensitivity close to 50%) and insufficient for their precise quantification. The CT scan is a more effective non-invasive method leading to an accurate analysis of the lesion before coronary angiography. IVUS and OCT have an excellent spatial resolution and are the most sensitive methods for the identification (present in nearly 75-80% of lesions) and quantification of calcifications. These intracoronary imaging techniques offer interesting perspectives for identification of the highest-risk lesions, PCI procedures planning (including the choice of an optimal dedicated plaque preparation devices), the monitoring of their execution and the evaluation of the immediate post-stenting results.

Impact of ultrasound reverberation in calcified coronary arteries: Intravascular ultrasound study

BACKGROUND AND AIMS

Intravascular ultrasound (IVUS) often allows us to observe reverberations behind calcification in percutaneous coronary intervention (PCI) to heavily calcified lesions. However, clinical significance of reverberations remains unknown. The aim of this study was to assess the impact of reverberations on stent expansion and clinical outcomes after PCI with rotational atherectomy (RA) to heavily calcified lesions.

METHODS

We considered 250 calcified lesions that underwent IVUS-guided PCI with RA. According to the number of reverberations (NR), those lesions were divided into the high NR (≥3) group (n = 36) and the low NR (≤2) group (n = 214). Stent expansion and the cumulative incidence of ischemia-driven target lesion revascularization (ID-TLR) were compared between the high and low NR groups.

RESULTS

The high NR group showed significantly smaller stent expansion rate than the low NR group (67.7% vs. 75.9%, respectively, p=0.02). The multivariate logistic regression analysis showed that high NR and calcified nodule were significantly associated with stent underexpansion. The incidence of ID-TLR was significantly higher in the high NR group than in the low NR group (p=0.03). In multivariate Cox hazard analysis, high NR and acute coronary syndrome were significantly associated with ID-TLR.

CONCLUSIONS

High NR was significantly associated with stent underexpansion and ID-TLR. When high NR was detected by IVUS, the PCI strategy was be planned carefully to avoid stent underexpansion. The follow-up program of the patients with high NR might need to be scheduled prudently because of the high risk of TLR.