Clinical Outcomes and Unique Restenosis of Calcified Nodule in Heavily Calcified Coronary Artery

Abstract

Aims: Calcified nodule (CN) has been known as the advanced stage of coronary calcification. However, clinical outcomes following percutaneous coronary intervention (PCI) to CN remain unknown. This study aimed to compare clinical outcomes, including target lesion revascularization (TLR), between calcified coronary lesions with and without CN. Methods: Two hundred forty-nine lesions undergoing intravascular ultrasound-guided PCI with rotational atherectomy (RA) were enrolled and divided into the CN group (n=100) and the non-CN group (n=149) according to the presence of CN. The cumulative incidence of clinically driven TLR (CD-TLR) and the reasons for CD-TLR were compared between the CN and non-CN groups.Results: The incidence of CD-TLR was significantly higher in the CN group than in the non-CN group. In the landmark analysis at 1 year, the CN group showed a significantly higher incidence of CD-TLR within 1 year. However, the incidence of CD-TLR beyond 1 year was numerically lower in the CN group than in the non-CN group. In the multivariate Cox hazard model, CN was significantly associated with CD-TLR. In the CN group, in-stent CN was the major reason for CD-TLR (52%) and was observed mainly within 1 year (90%). Conclusions:In the heavily calcified lesions requiring RA, CN was the factor associated with the higher rate of CD-TLR especially within 1 year. The timing of CD-TLR in lesions with CN may indicate that the process of CN protruding through the struts was progressed monthly.

Clinical Impact of Calcified Nodules in Patients with Severely Calcified Lesions Treated by Rotational Atherectomy: A Serial Optical Coherence Tomography Study

“…10,21 In our study, the MLA site at follow-up corresponded to the CN site at baseline in 84.6% of the CN group, supporting the hypothesis that CN at index PCI was related to in-stent CNs and subsequent TLR. Moreover, TLRs are reported to predominantly occur within 1 year, 6,10 and in-stent CNs are observed within the same timeframe after stenting. 8 Consistently, in this study, TLR incidence in the CN group was predominantly observed within 1 year.…”

“…Previous studies using intravascular ultrasound (IVUS) identified CN prevalence in 40.0–48.5% of calcified lesions requiring RA. 5,10,17 In this study, we observed CNs in 29.6% of the target lesions using OCT. We defined CNs as eruptive CNs, excluding calcified protrusion (defined without eruptive nodules), as distinguishing between these two types of protruding Ca using IVUS can be challenging. Consistent with our results, several OCT studies demonstrated an association between CN occurrence and older age, renal dysfunction, and hemodialysis.…”

Coronary calcifications, the Achilles heel in coronary interventions

“…Calcified nodules were found not to be significant by multi-variate analysis in the study conducted by Fujino et al [ 47 ]. However, recent trials demonstrated that the presence of calcified nodules predicted long-term target lesion revascularization (TLR) and late stent underexpansion, especially within the first year, with higher rates of majopr adverse cardiovascular events (MACE) [ 48 , 49 ]. Another study showed that compared to non-eruptive nodules, nodules of eruptive morphology by OCT were associated with worse post-PCI long-term clinical outcomes, despite better acute stent expansion [ 15 ].…”

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

“…Five articles comparing CNs versus N-CNs were finally included in our metaanalysis. 12,[25][26][27][28] Characteristics of the included studies Characteristics of the included studies are listed in Table 1. All five included papers comparing CNs versus N-CNs were observational in design.…”