Abrasion, grinding, pulverization, vaporization, and extraction: debulking options for percutaneous coronary interventions of calcified coronary lesions

Calcified coronary lesions present a unique challenge for patients undergoing percutaneous coronary interventions (PCI). A higher prevalence of calcific lesions is seen in men and older patients, while diabetes, chronic kidney disease, and tobacco use are significant risk factors. Calcific lesions have been associated with an increased risk of stent thrombosis, restenosis, and major adverse cardiac outcomes (MACE). Larger plaque burden and increased lesion complexity, such as bifurcation or chronic total occlusion, are commonly seen with calcific coronary lesions. Coronary calcifications lead to increased procedural complexity with difficulty in lesion preparation, balloon delivery and dilation, and stent delivery and expansion. Given the complexity, stent fracture, under expansion, or malapposition of stents lead to unfavorable outcomes such as thrombosis, myocardial infarction, or restenosis. A favorable result with stent implantation is predicted by final minimal stent area (MSA), larger stent areas lead to improved stent patency, achieved by appropriate modification of plaque morphology before stent implantation. Various interventions, such as specialty balloons and atherectomy, have been developed to overcome calcium burden and maximize MSA, thereby potentially improving PCI outcomes. In this chapter, we will focus on nonatherectomy (cutting, scoring, and lithotripsy) and atherectomy (rotational, orbital, and laser) strategies for calcific lesion modification before PCI.