Management strategies for heavily calcified coronary stenoses: an EAPCI clinical consensus statement in collaboration with the EURO4C-PCR group

Abstract

Since the publication of the 2015 EAPCI consensus on rotational atherectomy, the number of percutaneous coronary interventions (PCI) performed in patients with severely calcified coronary artery disease has grown substantially. This has been prompted on one side by the clinical demand for the continuous increase in life expectancy, the sustained expansion of the primary PCI networks worldwide and the routine performance of revascularization procedures in elderly patients; on the other side, the availability of new and dedicated technologies such as orbital atherectomy and intravascular lithotripsy, as well as the optimization of the rotational atherectomy system, have increased operators’ confidence in attempting more challenging PCI. This current EAPCI clinical consensus statement prepared in collaboration with the EURO4C-PCR group describes the comprehensive management of patients with heavily calcified coronary stenoses, starting with how to use non-invasive and invasive imaging to assess calcium burden and inform procedural planning. Objective and practical guidance is provided on the selection of the optimal interventional tool and technique based on the specific calcium morphology and anatomic location. Finally, the specific clinical implications of treating these patients are considered, including the prevention and management of complications, and the importance of adequate training and education.

Clinical and Procedural Outcomes of IVUS-Guided vs. Angiography-Guided CTO-PCI: A Systematic Review and Meta-Analysis

“…One of the most useful applications of IVUS when dealing with CTO is the assessment of the proximal cap. In fact, it is very useful both to resolve proximal cap ambiguity or to assess the presence and relevance of calcifications to select the most appropriate interventional strategy, as suggested in the recent EAPCI/EURO4C-PCR consensus [27]. Unfortunately, data on the use of IVUS to resolve the proximal cap and/or assess the calcium burden were not comprehensively reported across the studies.…”

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

“…The Rotablator System (Boston Scientific) is made up of a nickel-plated elliptic burr coated with diamond microscopic crystals, a single advancer that can transmit rotational speed to the burr, and is connected with a gas-driven turbine and a control console and foot pedal or an activator in the connecting handle (Figure 6, panel e) [39,66]. The most recent indications relative to the use of a Rotablator recommend a smaller burr size and standardized protocols (i.e., rotation speeds between 135,000 and 180,000 rpm) in order to reduce procedural complications [67]. Dedicated 330-mm long wires are available but their performance in heavily calcified vessels is not always optimal so they are often inserted through an over-the-wire balloon or microcatheter after a work-horse standard coronary wire has been used.…”

“…Of note, adjunctive wires are not allowed during rotablation to avoid wire cutting or perforation. From a practical point of view, short burr runs are usually preferred and fluoroscopic, acoustic, and tactile signals should be monitored to avoid significant deceleration in rotational speed (>5000 rpm), which is associated with complications [66,67]. The latter is also achieved thanks to the "pecking motion" technique, a forward-backward movement of the burr, ideated to reduce the effective ablation time.…”

“…The latter is also achieved thanks to the "pecking motion" technique, a forward-backward movement of the burr, ideated to reduce the effective ablation time. Although rotational atherectomy is still considered one of the best tools for debulking in calcified lesions, it has been found that in European countries the rate of rotational atherectomy as a function of the total PCI number is still low (0.8-3.1%) [67]. Such evidence is partly explained by the concern regarding the complexity of the Rotablator procedures and potential procedure-related complications occurring in the absence of standardized protocols.…”

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

“…Heavily calcified lesions IVUS and OCT play pivotal roles in the assessment of calcification and identification of high-risk features for stent under expansion [30,[124][125] . Several society expert position statements have sought to provide guidance on the optimal approach to calcified lesions that have incorporated the use of IVI techniques [27,[126][127] . However, there remains an unmet need for dedicated guidelines on the use of IVI to guide lesion modification decisions.…”