Current Treatment Modalities for Calcified Coronary Artery Disease: A Review Article Comparing Novel Intravascular Lithotripsy and Traditional Rotational Atherectomy

Abstract

The coronary artery calcium score is considered the most useful marker for predicting coronary events. The high score reflects heavy calcification in the vessel, which is more challenging to treat with the percutaneous intervention (PCI). To prepare this type of heavily calcified lesion intravascular lithotripsy (IVL) technology can be used prior to PCI, which is based on the concept of converting electrical energy into mechanical energy. It harmlessly and selectively disrupts both the shallow and deep deposits of calcium. The balloonbased catheters of this system emit sonic waves that transfer to the adjacent tissue resulting in improvement in vessel compliance with the slightest soft tissue loss. Therefore, making the treatment of calcified lesions more feasible, effective, and also simplify complex lesions. The lesions considered for lithotripsy-enhanced balloon dilation include calcified coronary lesions and peripheral vasculature lesions. This article reviews the use of IVL in calcified coronary artery disease, its advantages, and disadvantages while comparing it with other techniques like high-pressure balloons and rotational atherectomy devices. A thorough search of databases like PubMed and Google Scholar was performed, which uncovered 35 peer review articles. Keywords utilized in the data search were calcified coronary artery disease, coronary lithotripsy, calcification, and calcified atherosclerotic plaque. According to rotational atherectomy and intravascular lithotripsy trials, the latter was safer, mainly by decreasing atheromatous embolization risk. Deciphering these studies, it seems like IVL is better at parameters like procedural and clinical success rate, acute lumen gain, and less residual stenosis except in-hospital major adverse cardiovascular events (MACE), which was better in rotational atherectomy (RA). However, when lesion crossings are present, the atherectomy technique is still considered as first-line therapy. In clinical practice, despite these encouraging data for treating calcified lesions, IVL is grossly underutilized because of substantial costs and perceived significant procedural risk effects on the cardiac rhythm like causing 'shock topics' and asynchronous cardiac pacing. More longer-term clinical data and extensive researches are required to validate its safety and efficiency.

Shock Wave Intravascular Lithotripsy (IVL)-Assisted Staged Percutaneous Coronary Intervention (PCI) for a Calcified Right Coronary Artery in a Patient With Unstable Angina: Shock the Rock

“…Very tight calcified lesions may resist dilatation at low balloon inflation pressures or rupture at high pressures. This causes high rates of procedural complications and, consequently, poor clinical outcomes [ 6 ]. Recent therapeutic calcium debulking techniques used to overcome CAC can be categorized into two groups: non-balloon (rotational, orbital, and laser coronary atherectomy) and balloon-based technologies (high-pressure/ultra-high-pressure non-compliant balloon, scoring/cutting balloons, shockwave IVL balloon).…”

“…Derived from lithotripsy technology employed to treat nephrolithiasis [ 8 ], the shockwave IVL system has also proved to be beneficial in treating CAC. Compared to the aforementioned conventional approaches, the shockwave IVL system requires minimal training and provides excellent outcomes of luminal widening, successful stent implantation, and reduced risk of major adverse cardiovascular events [ 6 ]. These observations are noted in our case, too.…”

Guidezilla™ guide extension catheter I for transradial coronary intervention

“…Four patients received a drug-coated balloon. No significant differences were found in operation time and success rate among the low (<23), intermediate (23)(24)(25)(26)(27)(28)(29)(30)(31)(32), and severe (>32) CAD groups based on SYNTAX score stratification (P > 0.05). Two subacute thrombosis cases each were reported perioperatively, during hospitalization, and at the 1-month follow-up.…”

“…The European and American guidelines state that the anatomical SYNTAX score is an essential tool that could help clinicians choose the most appropriate revascularization strategy for patients with complex CAD-PCI or coronary artery bypass graft (CABG) surgery (15,16). Based on the anatomical severity of CAD, the patients can be categorized as low (<23), intermediate (23)(24)(25)(26)(27)(28)(29)(30)(31)(32), or severe (>32) category according to the SYNTAX score. It was found that low-and intermediatecategory patients have similar long-term outcomes regardless of the revascularization strategy implemented (15, 16).…”

Shock Wave Intravascular Lithotripsy: Shock the Rock

“…Coronary IVL (using the Shockwave IVL (S-IVL) (shockwave medical, Ins., Santa Clara, CA, USA), was approved in 2021. [24] IVL utilizing localized pulsatile sonic pressure waves at low pressure provides a novel approach for lesion preparation of severely calcified plaques. Electrohydraulic waves produced by IVL can disrupt subendothelial calcification, successfully fracturing circumferential calcium [25,26] [Table 2].…”