CALCIUM MODIFICATION

TECHNIQUES IN COMPLEX PCI

Dr. Thiều Minh Sơn, MD
Interventional Cardiology Fellow at
Khánh Hòa Provincial General Hospital
Nha Trang, July 20th 2023
 CONTENTS
1. Introduction

2. Calcification assessment

3. Calcium modification techniques

4. Conclusions
 01.
INTRODUCTION
 A
CORONARY ARTERY
CALCIFICATION
• Highly prevalent in patients with coronary heart
disease (CHD)
• Prevalence of CAC is age- and gender-dependent,
occurring in over 90% of men and 67% of women
B
older than 70 years of age
• Other risk factors: hypertension, diabetes mellitus,
dyslipidemia, chronic kidney disease, obesity, familial
history of CAC, high fibrinogen level, high CRP level
• 2 types of CAC: intimal and medial
• Associated with major adverse cardiovascular events
• Usually be found in patients with severe CHD, but can
be asymptomatic → early diagnosis is important
J Geriatr Cardiol 2015; 12: 668 675. doi:10.11909/j.issn.1671-5411.2015.06.012
PREVALENCE A

American Journal of Preventive Cardiology 12 (2022) 100392. DOI:https://doi.org/10.1016/j.ajpc.2022.100392

 A
PATHOGENIC MECHANISM
• Type 1: contains lipoproteins →
initiate an inflammatory response
• Type 2: accumulation of foam
cells
• Type 3: contains extracellular
lipid droplets
• Type 4: extracellular lipid pools B
form a lipid core
• Type 5: lipid core develops a
fibrous connective-tissue
thickening that can calcify →
detectable by imaging
• Type 6: complicated lesion that
can include thrombus from
plaque rupture
CAC score: coronary artery calcium score
Cleveland Clinic Journal of Medicine September 2018, 85 (9) 707-716; DOI: https://doi.org/10.3949/ccjm.85a.17097
 A
CLASSIFICATION
Calcium lesions:
• Superficial (intimal):
present at the intimal–
lumen interface or
closer to the lumen
than to the adventitia
• Deep (medial): located B
at the media/adventitia
border or closer to the
adventitia than to the
lumen.

Cleveland Clinic Journal of Medicine September 2018, 85 (9) 707-716; DOI: https://doi.org/10.3949/ccjm.85a.17097
 A
CALCIUM DISTRIBUTION

Front. Cardiovasc. Med., 06 April 2023. Sec. Cardiovascular Imaging. Volume 10 – 2023. DOI: https://doi.org/10.3389/fcvm.2023.1133510
 A
CORONARY ARTERY
CALCIFICATION
• Coronary lesions with severe
calcification are classified as complex
lesions
• Known to carry lower success rates
and higher complication rates B
following PCI
• Poses technical challenges during PCI
→ in stent under-expansion,
malapposition, or the inability to place
a stent
• May damage the polymer coating of
DES → DES ineffectiveness when
implanted
Catheter Cardiovasc Interv. 2020;doi:10.1002/ccd.28994
 A

Catheter Cardiovasc Interv. 2018 Apr 1;91(5):859-866. doi: 10.1002/ccd.27204. Epub 2017 Jul 19.
PREVALENCE A

J Am Heart Assoc. 2021;10:e022513. https://doi.org/10.1161/JAHA.121.022513

 02.
CALCIFICATION
ASSESSMENT
 IMAGING A

MODALITIES
Imaging modalities for identifying and
characterizing calcified coronary lesions:
• Coronary angiography
• Coronary CT angiography
• Intravascular imaging:
• Intravascular ultrasound (IVUS) B
• Optical coherence tomography (OCT)

Circulation. 2022;145:e18–e114. DOI: 10.1161/CIR.0000000000001038

 A

CORONARY
ANGIOGRAPHY
• Calcified lesions will appear as an area of
attenuation of the X-rays:
• Visible already before the contrast
injection B
• Arranged along the contour of the
vessel
• Moves with heart movement.
• Angiography alone has been shown to have
low sensitivity in identifying calcified lesions
→ necessary to combine with intravascular
imaging
European Heart Journal Supplements (2023) 25 (Supplement C), C68–C73
 A
CORONARY ANGIOGRAPHY

Example 1:
Left and right panels are B
coronary angiographic images
before and after the injection of
a radio-contrast agent,
respectively.
Arrows indicate presence of faint
radio-opaque lesions after the
injection of a radio-contrast →
mild calcification.
Kini, A., Sharma, S. K. (Eds.). (2021). Practical manual of interventional cardiology. Springer London. DOI: https://doi.org/10.1007/978-3-030-68538-6
Example 2: A
Both left and right panels are images
before the injection of a radio-contrast
agent. There is no radio-opaque lesion
during diastolic movement (left panel).
Arrows indicate the presence of
radio-opaque lesions during systolic
movement (right panel) → moderate
calcification

Example 3: B
Arrows indicate the presence of radio-
opaque lesions before the injection of a
radio-contrast agent irrespective of
heart movement (diastolic movement
on left panel and systolic movement on
right panel) → severe calcification

Tohoku J. Exp. Med., 2015, 235, 135-144

Coronary CT Angiography (CCTA) A

A: No CAC within the

partially imaged LAD
B: CAC involves <1/3
LAD length B
C: CAC involves 1/3 –
2/3 LAD length
D: CAC involves >2/3
LAD length and branch
vessels
E: Stent within the LAD
precludes CAC
assessment.
Clinical Imaging 77 (2021) 1–8. DOI: https://doi.org/10.1016/j.clinimag.2021.02.016
 A
CCTA INDICATIONS

Journal of Cardiovascular Computed Tomography 15 (2021) 290–303

 A
CCTA INDICATIONS

Journal of Cardiovascular Computed Tomography 15 (2021) 290–303

 A
CCTA features associated
with an increased risk of
MACE:
a. Extensive non-obstructive
calcified plaque in the
left main, proximal-mid LAD,
proximal LCX, and OM1
b. An atherosclerotic plaque
with positive remodeling,
B
low-attenuation plaque, and
napkin-ring sign in the
proximal LAD
c. ICA demonstrating
occlusion of the proximal
LAD at the site of high-risk
plaque 10 months after
coronary CTA (arrows).
Journal of Cardiovascular Computed Tomography 15 (2021) 290–303
 A
CCTA INDICATIONS

Diagnostics 2023, 13(12), 2074; https://doi.org/10.3390/diagnostics13122074

 A
CAC SCORE

Journal of Cardiovascular Computed Tomography 15 (2021) 290–303

PREVALENCE A

J Am Coll Cardiol Img 2017;10:923–37. DOI: https://doi.org/10.1016/j.jcmg.2017.05.007

PREVALENCE A

J Am Coll Cardiol Img 2017;10:923–37. DOI: https://doi.org/10.1016/j.jcmg.2017.05.007

PREVALENCE A

JACC: Cardiovascular Imaging, Volume 14, Issue 12,2021,Pages 2443-2452 ISSN 1936-878X, https://doi.org/10.1016/j.jcmg.2021.01.024.
 A
CCTA INDICATIONS

Curr Cardiovasc Imaging Rep (2015) 8:18. DOI 10.1007/s12410-015-9334-0

 A
Timeline of advances in
interventional cardiology

Current Cardiovascular Risk Reports 16(6). DOI:10.1007/s12170-021-00686-4

 A
IVUS/OCT
• The use of intracoronary imaging
to guide PCI improves procedural
and long-term clinical outcomes
• Provide important insights into
coronary lesion morphology →
detecting, localizing, and B
quantifying coronary calcification
• Assist with assessing the need for
lesion preparation, stent sizing,
minimizing geographic miss,
verifying stent expansion,
evaluating complications, and
identifying causes of stent failure

Circ Cardiovasc Interv. 2021;14:e009870. DOI: 10.1161/CIRCINTERVENTIONS.120.009870

 A
OCT/IVUS

• OCT and IVUS images from the same lesions

• Red dotted line: EEL (external elastic lamina)
• Yellow dotted line: internal elastic lamina
• Blue dotted line: lumen surface
• Yellow double arrowhead: (EEL) diameter
• White double arrow head: Lumen diameter
J Am Coll Cardiol Img. 2017 Dec, 10 (12) 1487–1503
OCT/IVUS A

• (A’) and (A’’) are OCT and IVUS

images corresponding to the arrow in
(A) in a patient with stable angina
who suffered peri-procedural
myocardial infarction after stenting
• A’: a large lipid rich plaque defined
by diffuse border with attenuation by
OCT B
• A’’: a large attenuated plaque
defined as echo attenuation without
hyperechoic leading edge by IVUS
• B (OCT) and B’ (IVUS) show calcified
plaque. The thickness of calcium can
be measured only by OCT (1.05 mm),
and the calcium angle measured 130
degree by both IVUS and OCT.

J Am Coll Cardiol Img. 2017 Dec, 10 (12) 1487–1503

 A
IMAGING MODALITIES

J Am Coll Cardiol Intv 2019;12:1465–78

 A

2021 ACC/AHA/SCAI
Guideline for Coronary
Artery Revascularization:
A Report of the
American College of B
Cardiology/American Heart
Association Joint Committee
on Clinical Practice
Guidelines

Circulation. 2022;145:e18–e114. DOI: 10.1161/CIR.0000000000001038

Severity Classification

J. Pers. Med. 2022, 12, 1638. DOI: https://doi.org/10.3390/jpm12101638

Severity Classification

J. Pers. Med. 2022, 12, 1638. DOI: https://doi.org/10.3390/jpm12101638

 03.
CALCIUM MODIFICATION
TECHNIQUES
 A

TECHNIQUES
Balloon-Based Devices:
• Non-Compliant Balloons
• High-Pressure (Dual-Layer)
Non-Compliant Balloons
• Cutting Balloons B
• Scoring Balloons
• Intravascular Lithotripsy
Coronary Atherectomy:
• Rotational Atherectomy
• Orbital Atherectomy
• Laser Atherectomy

Circ Cardiovasc Interv. 2021;14:e009870. DOI: 10.1161/CIRCINTERVENTIONS.120.009870

 BALLOON
COMPLIANCE
• Balloon compliance: the change in balloon diameter
per atmosphere of inflation pressure (“stretchability”
of a balloon) → approximately 0.095 mm/atm for
semi-compliant balloons, and 0.01 mm/atm for non-
compliant balloons B
• Semi-compliant balloons:
• Expand in diameter as the atmospheres increased
• May result in a “dog bone” shape as it expands in
a lesion
• Non-compliant balloons:
• Maintain a consistent diameter throughout their
length as they inflate, even at high pressures
Hoballah, J.J., Bechara, C.F. (2021) Vascular Reconstructions. Springer, New York, NY. https://doi.org/10.1007/978-1-0716-1089-3_22
 NON-COMPLIANT
BALLOONS (NCB)
• Single layer
• Can be expanded to high pressures (20–24
atm)
• Failure: B
• Eccentric calcium → guidewire bias may
direct force toward the non-calcified
segments of the artery
• Concentric calcium → insufficient force
fails to induce calcium fracture
• Possible complications: balloon rupture,
vessel dissection, or perforation

Circ Cardiovasc Interv. 2021;14:e009870. DOI: 10.1161/CIRCINTERVENTIONS.120.009870

 B

Cuculi F, et al. Open Heart 2020;7:e001204. doi:10.1136/openhrt-2019-001204

 B

Cuculi F, et al. Open Heart 2020;7:e001204. doi:10.1136/openhrt-2019-001204

 B
CONCLUSIONS:
In simple coronary lesions, predilatation/
postdilatation with NCBs at high pressures
appears to be safe and result in better scaffold
and stent expansion.
Using SCBs only for predilatation might lead to
inadequate stent expansion and postdilatation
with NCBs might only partially correct this.

Cuculi F, et al. Open Heart 2020;7:e001204. doi:10.1136/openhrt-2019-001204

 HIGH-PRESSURE
NC BALLOONS
• Dual layer
• Low profile
• Can exert super high pressures on the lesion
(35atm rated pressure)
• Data for this device are limited to small case series,
but all portray a device that is simple to use and B
effective, with no signal of increased risk
• When conventional NCB’s fail → high-pressure NC
balloons provide an effective strategy
• It remains unclear when this device would be of
definitive benefit → lesion selection remains
challenging
• Potential risk: coronary dissection, perforation,
localized wall injury (may provide a substrate for
restenosis)

Circ Cardiovasc Interv. 2021;14:e009870. DOI: 10.1161/CIRCINTERVENTIONS.120.009870

 B

Catheter Cardiovasc Interv. 2010 Jun 1;75(7):1067-73. doi: 10.1002/ccd.22430.

 B

Am J Cardiol . 1995 Sep 1;76(7):518-20. doi: 10.1016/s0002-9149(99)80143-x.

 B

Cardiovasc Revasc Med. 2019 Dec;20(12):1083-1087. doi: 10.1016/j.carrev.2019.02.026. Epub 2019 Mar 1.
 B

RESULTS:
Angiographic success was achieved in 97.5%,
procedural success in 96.6%.
The OPN alone was able to achieve adequate
expansion in >90%. 0.9% days MACE were reported.
CONCLUSION: The OPN-dedicated high-pressure
balloon provides an effective and safe strategy for
treatment of severe resistant coronary lesions.
Cardiovasc Revasc Med. 2019 Dec;20(12):1083-1087. doi: 10.1016/j.carrev.2019.02.026. Epub 2019 Mar 1.
 CUTTING
BALLOON
• First developed in the mid-1980s by Dr.
Peter Barath → initially called the Barath
Balloon
• Composed of a conventional balloon with
three or four atherotomes (microsurgical B
blades) that are mounted longitudinally
along the balloon surface
• Provides a focused force at low pressure →
create controlled incisions along the lesion
length → greater vessel compliance +
improved stent expansion
• Cons: bulky device → difficulty in
delivering
Hoballah, J.J., Bechara, C.F. (2021) Vascular Reconstructions. Springer, New York, NY. https://doi.org/10.1007/978-1-0716-1089-3_22
 CUTTING
BALLOON
• The diameter of the cutting balloon is
selected to approximate a 1.0 : 1.1
ratio (balloon to the reference vessel
diameter) → oversizing increases the
risk of perforation and rupture
• Balloon lengths are often shorter than B
conventional balloons, usually 15–20
mm
• Should be inflated and deflated slowly
(generally 1 atm every 2–3 seconds) to
avoid damaging their structural
integrity
• Some authors advocate rotating the
balloon and inflating it multiple times
to score the lesion
Hoballah, J.J., Bechara, C.F. (2021) Vascular Reconstructions. Springer, New York, NY. https://doi.org/10.1007/978-1-0716-1089-3_22
 CUTTING
BALLOON

Figure 6. Optical coherence tomography (OCT) images of cutting balloon use.

A, Pre-percutaneous coronary intervention OCT image deep (0.90 mm) calcific nodule (lower left quadrant) encroaching on vessel lumen.
Minimal luminal area in this segment is 3.51 mm2.
B, OCT image immediately following 1:1 sized cutting balloon, showing improved minimal luminal area (7.52 mm2) and signs of vessel
preparation with balloon-associated dissection evident (at 7 and 9 o’clock).
Am J Cardiol . 1995 Sep 1;76(7):518-20. doi: 10.1016/s0002-9149(99)80143-x.
 B

J. Pers. Med. 2022, 12, 1638. DOI: https://doi.org/10.3390/jpm12101638

 B

J Geriatr Cardiol 2014; 11: 44−49. doi: 10.3969/j.issn.1671-5411.2014.01.012

 B

CONCLUSIONS:
Cutting balloon angioplasty before DES
implantation in severely calcified lesions
appears to be more efficacies including
significantly larger final stent CSA and larger
acute lumen gain, without increasing
complications during operations and the
MACE rate in 6-month.
J Geriatr Cardiol 2014; 11: 44−49. doi: 10.3969/j.issn.1671-5411.2014.01.012
 B

J Invasive Cardiol. 2015 Sep;27(9):387-91.

 B

CONCLUSIONS:
A strategy of lesion preparation with RA, POBA, or CBA in
HCCL may be associated with similar clinical outcomes in
patients undergoing percutaneous intervention with DES.
The RA group had a trend toward greater MACE, death,
and TLR.
J Invasive Cardiol. 2015 Sep;27(9):387-91.
 SCORING
BALLOON
• Consist of a semi-compliant balloon
with 3-4 rectangular nitinol-based
struts that encircle the balloon in a B
helical pattern
• Mechanistic evolution of the CB:
• Reducing the mechanical trauma
exerted on the vessel wall →
lower risk of dissection
• More deliverable

Circ Cardiovasc Interv. 2021;14:e009870. DOI: 10.1161/CIRCINTERVENTIONS.120.009870

 B

Cardiovasc Interv Ther. 2019 Jul;34(3):242-248. doi: 10.1007/s12928-018-0553-6. Epub 2018 Oct 19.
 SCORING
BALLOON

A: Cross-sectional coronary calcification. B: The image shows the thicknesses of the calcifications (520, 470, and 440 µm),
and 3 disruption sites can be seen (after modification by scoring balloon). In this case, the coronary calcification angle
was 360° and the shape was non-convex
Cardiovasc Interv Ther. 2019 Jul;34(3):242-248. doi: 10.1007/s12928-018-0553-6. Epub 2018 Oct 19.
 B

J. Pers. Med. 2022, 12, 1638. DOI: https://doi.org/10.3390/jpm12101638

SCORING
BALLOON

Int J Cardiol. 2016 Oct 15;221:23-31. doi: 10.1016/j.ijcard.2016.07.002. Epub 2016 Jul 4.
SCORING
BALLOON

Int J Cardiol. 2016 Oct 15;221:23-31. doi: 10.1016/j.ijcard.2016.07.002. Epub 2016 Jul 4.
SCORING
BALLOON

Int J Cardiol. 2016 Oct 15;221:23-31. doi: 10.1016/j.ijcard.2016.07.002. Epub 2016 Jul 4.
OUTCOMES
RESULTS:
Stent expansion was significantly higher after
predilation by a scoring balloon (68.0% vs.
62.1%, p = 0.017) with similar stent lumen
eccentricity (0.84 vs. 0.80, p = 0.18).
Intimal disruption was induced significantly
more frequently (68.0% vs. 38.4%, p = 0.035)
B
and was more extensive in the scoring group
(122° vs. 65°, p = 0.038).
Adverse clinical events including death,
myocardial infarction, and stent thrombosis
were not observed up to 9 months after PCI
in both groups.
CONCLUSIONS:
In this randomized study, pretreatment with
a scoring balloon enhanced stent expansion
partly through induction of intimal disruption
Int J Cardiol. 2016 Oct 15;221:23-31. doi: 10.1016/j.ijcard.2016.07.002. Epub 2016 Jul 4.
 INTRAVASCULAR
LITHOTRIPSY
(IVL)
• Terminology: Lithotripsy = breaking stones
(Greek) B
• A non-invasive procedure involving the physical
destruction of hardened masses like kidney
stones or gallstones
• Techniques:
• Extracorporeal shockwave lithotripsy
(ESWL)
• Intracorporeal shockwave lithotripsy (ISWL)
• Intravascular lithotripsy (IVL)
J Am Coll Cardiol Intv 2021;14:1275–92
MECHANISM

J Am Coll Cardiol Intv 2021;14:1275–92

MECHANISM

J Am Coll Cardiol Intv 2021;14:1275–92

 MECHANISM
• Energy discharged from the spark gap between 2
electrodes → formation of a plasma vapor
bubble in the saline/contrast mixture within the
balloon → rapidly expanding and collapsing →
generates high-amplitude ultrasonic pressure
shockwaves → expands spherically outwards
from the emitters
• Shockwaves creates fracturing effects when B
encounters tissue with differing acoustic
impedances, but travel through (with minimal
effect) when encounters tissue with similar
acoustic impedance
• Acoustic impedance:
• Water: 1.500.000 kg/m2/s
• Kidney: 1.600.000 kg/m2/s
• Muscle: 1.700.000 kg/m2/s
• Calcified tissue: 7.800.000 kg/m2/s
Interventional Cardiology Review 2019;14(3):174–81. DOI: https://doi.org/10.15420/icr.2019.18.R1
IVL SHOCKWAVE
GENERATION
(A) The intravascular lithotripsy (IVL) balloon
catheter is positioned across the target
lesion (sized with a ratio of 1:1 with the
target vessel, advanced over a standard
work-horse guidewire) and inflated to 4
atm B
(B) Emitter spark gap discharge produces
compressive shockwaves that emanate
spherically outward; vapor bubble
formation is contained with the
integrated balloon.
(C) IVL shockwaves affect superficial and
deep calcium
(D) After IVL therapy is delivered, the balloon
is inflated to 6 atm prior to deflation.
J Am Coll Cardiol Intv 2021;14:1275–92
OCT Characterization of Calcified
Lesions and the Effects of
Lithoplasty and Stenting
(A) OCT cross sections acquired before
lithoplasty in 3 different segments of a
calcified lesion
(B) Post-lithoplasty, there were multiple
fractures noted in the same frames
(arrows), with an overall increase in Bthe
luminal area
(C) After implantation of drug-eluting
stents, the fractures were noted to
become deeper (arrows), with further
increase in acute area gain, resulting in
favorable stent expansion and
apposition.

J Am Coll Cardiol Img 2017;10:897–906

(A) Pre-PCI CAG shows
significant calcified
plaques in RCA
(B) Inflated NC balloon
shows dog boning
indicating unyielding
calcified lesion
(C) Post-PCI CAG shows
fully expanded stent
deployed after IVL
B
modification
(D) Pre-IVL IVUS imaging
shows a superficial 360
degree arch of
superficial calcium
(E) IVUS post-IVL shows
calcified plaque after
IVL, which shows
fractures.
JACC: Asia. 2023 Apr, 3 (2) 185–197
(A) Pre-PCI CAG showing
diffuse ISR (in-stent
restenosis) in RCA
(B) Pre-IVL IVUS showing
the under-deployed
stent and calcified ISR
(C) Inflated NC shows
under-expansion, B
indicating an unyielding
calcified lesion
(D) Post-IVL IVUS shows
some expansion of the
stent in the lesion
(E) The fully expanded
stent after IVL
(F) Post-PCI CAG showing
the fully expanded stents
JACC: Asia. 2023 Apr, 3 (2) 185–197
 B

J. Pers. Med. 2022, 12, 1638. DOI: https://doi.org/10.3390/jpm12101638

 B

J Am Coll Cardiol Intv. 2021 Jun, 14 (12) 1337–1348

 B

J Am Coll Cardiol Intv. 2021 Jun, 14 (12) 1337–1348

 B

CONCLUSIONS:
In the largest cohort of patients treated with coronary IVL
assessed to date, coronary IVL safely facilitated
successful stent implantation in severely calcified
coronary lesions with a high rate of procedural success.

J Am Coll Cardiol Intv. 2021 Jun, 14 (12) 1337–1348

 CORONARY ATHERECTOMY

Rotational atherectomy Orbital atherectomy Laser atherectomy

Interventional Cardiology Review 2019;14(3):182–9. DOI:https://doi.org/10.15420/icr.2019.17.R1
 ROTATIONAL
ATHERECTOMY
• RA uses a diamond encrusted elliptical
burr passed into the coronary artery
over a specialized 0.009 inch guidewire
(Rotawire) B
• The burr rotates at speeds of 140.000 to
220.000 rpm (monodirectional) and
abrades non-elastic, fibro-calcified
tissue into small particles (<10 μm) while
deflecting off softer elastic tissue
• The debris from the lesion passes
downstream and cleared by the
reticuloendothelial system.
Circ Cardiovasc Interv. 2021;14:e009870. DOI: 10.1161/CIRCINTERVENTIONS.120.009870
 B

Interventional Cardiology Review 2019;14(3):182–9. DOI:https://doi.org/10.15420/icr.2019.17.R1

 ROTATIONAL
ATHERECTOMY
• Historically had increased peri-
procedural and post-procedural
complications, with complication
rates as high as 9.7%
• Most complications are common to B
all PCI procedures
• Some risks are unique to RA:
• Burr entrapment
• RotaWire fracture
• No flow/slow flow
• Atrio-ventricular block requiring
trans-venous pacing
Circ Cardiovasc Interv. 2021;14:e009870. DOI: 10.1161/CIRCINTERVENTIONS.120.009870
COMPLICATIONS

Interventional Cardiology Review 2019;14(3):182–9. DOI:https://doi.org/10.15420/icr.2019.17.R1

 B

Interventional Cardiology Review 2019;14(3):182–9. DOI:https://doi.org/10.15420/icr.2019.17.R1

 B

J. Pers. Med. 2022, 12, 1638. DOI: https://doi.org/10.3390/jpm12101638

 B

Circulation: Cardiovascular Interventions. 2018;11:e007415. DOI: https://doi.org/10.1161/CIRCINTERVENTIONS.118.007415

 B

Circulation: Cardiovascular Interventions. 2018;11:e007415. DOI: https://doi.org/10.1161/CIRCINTERVENTIONS.118.007415

 B

CONCLUSION:
In patients with severely calcified coronary lesions:
• Elective RA is feasible in nearly all patients and the acute success rate is superior to modified balloons.
• Both approaches (elective RA and balloon plus bailout RA) are equally safe and effective.
• Use of RA is no longer associated with excessive LLL (late-lumen-loss) in the era of modern SES.
Circulation: Cardiovascular Interventions. 2018;11:e007415. DOI: https://doi.org/10.1161/CIRCINTERVENTIONS.118.007415
 ORBITAL
ATHERECTOMY
• A relatively recent advancement in the field of
atheroablation
• FDA approval in 2013
• Used a burr with a diamond-coated crown that
B
orbits in an elliptical path within the artery
• Pass over a specialist 0.014′′ wire (ViperWire)
• The crown’s ablates the calcified lumen→ produces
smaller particles of debris<2 μm
• Unlike RA, there is continuous blood flow through
the artery during ablation → potentially reduce the
risk of slow-flow/no reflow, decrease thermal injury
and obviate the need for the routine use of
temporary pacing
Circ Cardiovasc Interv. 2021;14:e009870. DOI: 10.1161/CIRCINTERVENTIONS.120.009870
 Eccentrically mounted
diamond-coated
crown uses centrifugal
force to orbit →
bidirectional burr
(a) one rotational cycle
(b) one orbital cycle
observed by high-speed
camera in axial direction
B at
when the crown rotates
90,000 rpm
(c) front and (d)
perspective schematic
views of the crown
rotation and orbiting.

J. Pers. Med. 2022, 12, 1638. DOI: https://doi.org/10.3390/jpm12101638

 MECHANISM OF ACTION
Crown will only Soft components
sand the hard (plaque/tissue)
components of flex away from the
the plaque crown

B
DIFFERENTIAL ORBITAL SANDING

ORBITAL MECHANISM:
Increased speed → Increased centrifugal force
Greater centrifugal force → Larger orbital diameter
J. Pers. Med. 2022, 12, 1638. DOI: https://doi.org/10.3390/jpm12101638
 ORBITAL Eccentric head
wobbles

ATHERECTOMY
• The crown’s orbital diameter expands
radially with increasing centrifugal
force → allows the operator to
Cutting head
control the depth of the ablation (by diamonds
varying the speed of the burr) → B
avoids the need to change the burr
multiple times + increasing procedural
efficiency
• Owing to the elliptical mechanism of
action, OA is contraindicated in vessel
diameters <2.5mm due to increased
risk of vessel perforation
Circ Cardiovasc Interv. 2021;14:e009870. DOI: 10.1161/CIRCINTERVENTIONS.120.009870
 B

J. Pers. Med. 2022, 12, 1638. DOI: https://doi.org/10.3390/jpm12101638

 B

JACC Cardiovasc Interv. 2014 May;7(5):510-8. doi: 10.1016/j.jcin.2014.01.158.

Primary Safety Endpoint

JACC Cardiovasc Interv. 2014 May;7(5):510-8. doi: 10.1016/j.jcin.2014.01.158.

Primary Efficacy Endpoint
Conclusions:
The ORBIT II coronary OAS trial
met both the primary safety
and efficacy endpoints by
significant margins.
Preparation of severely calcified
B
plaque with the OAS not only
helped facilitate stent delivery,
but improved both acute and
30-day clinical outcomes
compared with the outcomes of
historic control subjects in this
difficult-to-treat patient
population.
JACC Cardiovasc Interv. 2014 May;7(5):510-8. doi: 10.1016/j.jcin.2014.01.158.
LASER ATHERECTOMY
• Excimer laser coronary angioplasty (ELCA)
uses a pulse waved, ultraviolet laser catheter
to vaporize cadaveric atherosclerotic tissue
with minimal thermal damage
• Has been available for >25 years for the
percutaneous treatment of coronary artery
stenoses
• Was shown to be effective in coronary lesions B
poorly treated with balloon angioplasty alone,
including aorto-ostial lesions, long calcified
lesions, and saphenous vein graft (SVG)
lesions.
• ELCA is one of the most useful techniques in
calcified lesions that are truly uncrossable
• Use of ELCA in PCIs has seen an increase,
although overall use remains low
Circulation: Cardiovascular Interventions. 2021;14. DOI: https://doi.org/10.1161/CIRCINTERVENTIONS.120.010061
EQUIPMENTS
The Spectranetics CVX-300 Excimer
Laser System:
• Pulse generator (A)
• Control panel (B)
• ELCA catheters (C)
• Foot pedal (D)

Interventional Cardiology Review, 2016;11(1):27–32. DOI: 10.15420/icr.2016:2:2

 MECHANISM
• Excimer lasers are pulsed gas lasers that use a mixture
of a rare gas and halogen as an active medium to
generate pulses of short wavelength, high-energy
ultraviolet (UV) light.
• Tissue ablation is carried out by 3 distinct mechanisms:
• Photochemical: UV laser light is absorbed by intra-
vascular material and breaks carbon–carbon B
bonds
• Photothermal: UV laser light elevates the
temperature of intra-cellular water → cellular
rupture and generates a vapour bubble at the
catheter tip
• Photomechanical: Expansion and implosion of the
vapour bubbles disrupts the obstructive intra-
vascular material

Interventional Cardiology Review, 2016;11(1):27–32. DOI: 10.15420/icr.2016:2:2

 LASER CATHETERS
• Catheters comes in sizes of 0.9, 1.4, 1.7, and
2.0mm
• Laser catheter size selection is primarily based
on:
• Severity of the lesion
• Reference vessel diameter
• Consistency of the target material
• The 0.9- and 1.4-mm catheter are most B
commonly used and can be used in vessels >2.0
mm in diameter through a 6F guiding catheter
• The larger diameter laser catheters (1.7, 2.0
mm) are primarily used in straight sections of
vessels with a diameter >3.0 mm and require 7F
and 8F guiding catheters, respectively.
• Passed along a standard 0.014′′ work-horse
guidewire → not require dedicated guidewires
(that are often more difficult to deliver distally)
Circ Cardiovasc Interv. 2021;14:e009870. DOI: 10.1161/CIRCINTERVENTIONS.120.009870
MECHANISM

Cardiovascular Revascularization Medicine, https://doi.org/10.1016/j.carrev.2020.10.016

 PROS & CONS
• Provides a solution to a variety of
problems that may be encountered,
including:
• Massive intra-coronary thrombus
• Uncrossable lesions
• Stent under-expansion. B
• CONS:
• Expensive equipment, particularly
if only used sparingly for PCI cases
• Complexity surrounding its use (for
example, operators and staff have
to wear additional eye-protection
to prevent retinal exposure to UV
light)
Circ Cardiovasc Interv. 2021;14:e009870. DOI: 10.1161/CIRCINTERVENTIONS.120.009870
 B

J. Pers. Med. 2022, 12, 1638. DOI: https://doi.org/10.3390/jpm12101638

 B

Lancet. 1996 Jan 13;347(8994):79-84. doi: 10.1016/s0140-6736(96)90209-3.

OUTCOMES

CONCLUSION: ELCA followed by balloon angioplasty

provides no benefit additional to balloon
angioplasty alone with respect to the initial and
long-term clinical and angiographic outcome in the
treatment of obstructive coronary artery disease.
Lancet. 1996 Jan 13;347(8994):79-84. doi: 10.1016/s0140-6736(96)90209-3.
CORONARY ATHERECTOMY

Interventional Cardiology Review 2019;14(3):182–9. DOI:https://doi.org/10.15420/icr.2019.17.R1

 B

JACC: Asia. 2023 Apr, 3 (2) 185–197

 B

Circ Cardiovasc Interv. 2021;14:e009870. DOI: 10.1161/CIRCINTERVENTIONS.120.009870

 B

JACC: Asia. 2023 Apr, 3 (2) 185–197

 B

JACC: Asia. 2023 Apr, 3 (2) 185–197

CALCIUM MODIFICATION
TREATMENT ALGORITHM

Circ Cardiovasc Interv. 2021;14:e009870. DOI: 10.1161/CIRCINTERVENTIONS.120.009870 - European Heart Journal Supplements (2023) 25 (Supplement C), C68–C73
 B

Catheter Cardiovasc Interv. 2020;doi:10.1002/ccd.28994

 CONCLUSIONS
1. Coronary artery calcification represents a major challenge associated with adverse
outcomes after PCI
2. To avoid stent failure, optimal plaque preparation of calcified coronary lesions is required
3. Intracoronary imaging and determination of coronary calcification severity and
characteristics are the keys to guiding further treatment decisions.
4. Available modification techniques includes: Balloon-Based Devices (Non-Compliant
Balloons, High-Pressure Non-Compliant Balloons, Cutting Balloons, Scoring Balloons,
Intravascular Lithotripsy) and Coronary Atherectomy (Rotational Atherectomy, Orbital
Atherectomy, Laser Atherectomy)
5. The decision relating to which modification technique to use is based on numerous
anatomic and technical factors, including the location of the lesion, the concentricity of the
calcium pool, operator familiarity/expertise, and local device availability.