Contemporary Management of Severely Calcified Coronary Lesions

Abstract

Coronary artery calcification is increasingly prevalent in our patient population. It significantly limits the procedural success of percutaneous coronary intervention and is associated with a higher risk of adverse cardiovascular events both in the short-term and long-term. There are several modalities for modifying calcified plaque, such as balloon angioplasty (including specialty balloons), coronary atheroablative therapy (rotational, orbital, and laser atherectomy), and intravascular lithotripsy. We discuss each modality’s relative advantages and disadvantages and the data supporting their use. This review also highlights the importance of intravascular imaging to characterize coronary calcification and presents an algorithm to tailor the calcium modification therapy based on specific coronary lesion characteristics.

Revascularização Percutânea de Lesões Coronárias Severamente Calcificadas – Relato de Caso e Revisão de Literatura

“…Em três anos de evolução, a ocorrência de eventos incluindo mortalidade por todas as causas, morte cardíaca e infarto agudo do miocárdio e desfecho composto de morte, infarto e nova revascularização, foram significativamente mais frequentes em pacientes com LCSC. [3][4][5] A análise de LCSC através de imagem intravascular, seja pelo USIC ou pela tomografia de coerência ótica (OCT), é indispensável para o seu correto manuseio. Tanto o USIC quanto a OCT podem identificar, localizar e quantificar o cálcio na artéria coronária, informações importantíssimas para a estratégia de preparo da lesão.…”

“…Existem scores validados para estimativa de subexpansão de stent e necessidade de modificação de placa. 4,5 As diretrizes de 2021 do American College of Cardiology/American Heart Association /Society for Cardiovascular Angiography and Interventions (ACC/AHA/SCAI) recomendam o uso de imagem em casos complexos (recomendação de Classe 2a, nível de evidência B). 6 Existem várias ferramentas utilizadas para modificação de placas severamente calcificadas: cateter-balão não complacente (BNC), balões de alta-pressão (HPB), cateter-balão com lâminas "cutting-balloon" (CB), aterectomia rotacional (AR), aterectomia orbital (AO), aterectomia a laser (AL) e mais recentemente a litotripsia intravascular coronária (IVL) (Figura 4).…”

Intravascular lithotripsy: A novel option for severe calcification of coronary artery

“…According to the location distribution of calcification, calcified plaques can be divided into superficial calcification (located in the inner membrane and in contact with the lumen), deep calcification (near the junction of the media and outer membrane), and mixed calcification 7 . The IVUS calcification score (Figure S) indicated that both lesions with a calcification angle >270° and a length >5 mm, with a 360° annular calcification, with a reference vessel diameter ≤3.5 mm and with calcification nodules were given one point, respectively 8 . IVUS can provide sufficient spatial resolution, penetration depth, and real‐time vascular cross‐sectional images, 9 but ultrasonic waves are reflected by deposited calcium, accompanied by black sound shadows behind calcification.…”

“…An OCT scoring system (Figue S) was proposed to evaluate the severity of calcification lesions: There are two points for calcification angle >180° and one point for calcification angle 90–180°. The calcification thickness >0.5 mm is one point, and the calcification length >5 mm is one point 8 . OCT has a limited penetration capacity, but light can penetrate calcification without being reflected 1 .…”

“…There is a high risk of entanglement during the application of a Lacrosse nonslip element balloon 6 . The use of cutting and scoring balloons in severe calcification lesions and a lesion that standard predilated balloons cannot pass are limited 4,8 . ELCA has limited efficacy in severe calcification lesions and is not routinely recommended.…”