Contemporary approach to heavily calcified lesions: tools of the trade, challenges, and pitfalls

Abstract

Coronary artery calcifications (CAC) affect more than 90% of men and more than 67% of women older than 70; the spread is mainly due to the high occurrence of major cardiovascular risk factors. The presence of CAC can be detected by several noninvasive and invasive methods like computed tomography (CT), coronary angiography (CA), Intravascular Ultrasound (IVUS), and Optical Coherence Tomography (OCT), with each system providing different information that can be used in the treatment strategy of CAC. Several devices can modify calcium during PCI: high-pressure non-compliant balloons, cutting/scoring balloons, atheroablative technologies, and intravascular Lithotripsy (IVL). Each technique has advantages and disadvantages that every interventional cardiologist should know to perform an optimal PCI and to achieve the best result and clinical outcome. This is a narrative review that aims to illustrate the contemporary management of CAC, focusing on the available techniques to assess calcifications and their novel advancements and explaining the existing tools to treat CAC with a focus on their significant challenges and pitfalls.

Keywords

Coronary artery calcifications / percutaneous coronary intervention / intravascular imaging / debulking technique

References

[1] Bourantas CV,Garg S.Prognostic implications of coronary calcification in patients with obstructive coronary artery disease treated by percutaneous coronary intervention: a patient-level pooled analysis of 7 contemporary stent trials.Heart2014;100:1158-64

[2] Abdelrahman KM,Dey AK.Coronary computed tomography angiography from clinical uses to emerging technologies: JACC state-of-the-art review.J Am Coll Cardiol2020;76:1226-43 PMCID:PMC7480405

[3] Newby DE,Berry C.Coronary CT angiography and 5-year risk of myocardial infarction.N Engl J Med2018;379:924-33.

[4] Busse A,Beller E.Cardiac CT: why, when, and how: update 2019. Herz-CT: warum, wann und wie..Radiologe2019;59:1-9

[5] Budoff MJ,Burke G.Ten-year association of coronary artery calcium with atherosclerotic cardiovascular disease (ASCVD) events: the multi-ethnic study of atherosclerosis (MESA).Eur Heart J2018;39:2401-8 PMCID:PMC6030975

[6] Willemink MJ,Maurovich-Horvat P.Cardiac CT imaging of plaque vulnerability: hype or hope?.Curr Cardiol Rep2016;18:37

[7] Irkle A,Lewis DY.Identifying active vascular microcalcification by ¹⁸F-sodium fluoride positron emission tomography.Nat Commun2015;6:7495

[8] Dweck MR,Joshi NV.Coronary arterial ¹⁸F-sodium fluoride uptake: a novel marker of plaque biology.J Am Coll Cardiol2012;59:1539-48

[9] Rosa GM,Masoero G.The vulnerable coronary plaque: update on imaging technologies.Thromb Haemost2013;110:706-22

[10] Wang Y,Tung B,Li Y.Imaging cardiovascular calcification.J Am Heart Assoc2018;7:e008564. PMCID:PMC6064897

[11] Sheahan M,Paik D.Atherosclerotic plaque tissue: noninvasive quantitative assessment of characteristics with software-aided measurements from conventional CT angiography.Radiology2018;286:622-31 PMCID:PMC5790306

[12] Qiao J,Yang H.Subtraction improves the accuracy of coronary CT angiography in patients with severe calcifications in identifying moderate and severe stenosis: a multicenter study.Acad Radiol2023;30:2801-10

[13] Sun Z.Artificial intelligence (enhanced super-resolution generative adversarial network) for calcium deblooming in coronary computed tomography angiography: a feasibility study.Diagnostics2022;12:991 PMCID:PMC9027004

[14] Fink N,Schoepf UJ.Photon counting detector CT-based virtual noniodine reconstruction algorithm for in vitro and in vivo coronary artery calcium scoring: impact of virtual monoenergetic and quantum iterative reconstructions.Invest Radiol2023;58:673-80

[15] Andreini D,Leipsic J.Pre-procedural planning of coronary revascularization by cardiac computed tomography.J Cardiovasc Comput Tomogr2022;16:558-72

[16] Kurogi K,Nagatomo T.Mean density of computed tomography for predicting rotational atherectomy during percutaneous coronary intervention.J Cardiovasc Comput Tomogr2023;17:120-9

[17] Simsek B,Kostantinis S.Preprocedural coronary computed tomography angiography in chronic total occlusion percutaneous coronary intervention: insights from the PROGRESS-CTO registry.Int J Cardiol2022;367:20-5

[18] Yu CW,Suh J.Coronary computed tomography angiography predicts guidewire crossing and success of percutaneous intervention for chronic total occlusion: Korean multicenter CTO CT registry score as a tool for assessing difficulty in chronic total occlusion percutaneous coronary intervention.Circ Cardiovasc Imaging2017;10:e005800

[19] Available from: https://www.eurocto.eu/slides/en-GB/526/session-6-ct-guided-cto-pci [Last accessed on 26 Feb 2024]

[20] Panuccio G,Erbay A.Impact of coronary computed tomography angiography derived full Moon calcifications in CTO-PCI.Eur Heart J2023;44:ehad655.2203

[21] Dini C, Nardi G, Ristalli F, Mattesini A, Hamiti B, Di Mario C. Contemporary approach to heavily calcified coronary lesions.Interv Cardiol2019;14:154-63 PMCID:PMC6918474

[22] Hennessey B,Macaya F.Contemporary percutaneous management of coronary calcification: current status and future directions.Open Heart2023;10:e002182 PMCID:PMC9936324

[23] Wang X,Mintz GS.In vivo calcium detection by comparing optical coherence tomography, intravascular ultrasound, and angiography.JACC Cardiovasc Imaging2017;10:869-79

[24] Zaffino P,Indolfi C.CoroFinder: a new tool for real time detection and tracking of coronary arteries in contrast-free cine-angiography.J Pers Med2022;12:411 PMCID:PMC8951569

[25] Piayda K,Afzal S.Dynamic coronary roadmapping during percutaneous coronary intervention: a feasibility study.Eur J Med Res2018;23:36 PMCID:PMC6069549

[26] Friedrich GJ,Mühlberger VA.Detection of intralesional calcium by intracoronary ultrasound depends on the histologic pattern.Am Heart J1994;128:435-41

[27] Kawasaki M,Bressner J.Diagnostic accuracy of optical coherence tomography and integrated backscatter intravascular ultrasound images for tissue characterization of human coronary plaques.J Am Coll Cardiol2006;48:81-8

[28] Witzenbichler B,Weisz G.Relationship between intravascular ultrasound guidance and clinical outcomes after drug-eluting stents: the assessment of dual antiplatelet therapy with drug-eluting stents (ADAPT-DES) study.Circulation2014;129:463-70

[29] Choi KH,Lee JM.Impact of intravascular ultrasound-guided percutaneous coronary intervention on long-term clinical outcomes in patients undergoing complex procedures.JACC Cardiovasc Interv2019;12:607-20

[30] Zhang M,Usui E.Intravascular ultrasound-derived calcium score to predict stent expansion in severely calcified lesions.Circ Cardiovasc Interv2021;14:e010296

[31] You W,Xu T.Preliminary study of the significance of reverberation by IVUS detection for patients with severe calcified lesions.Int J Cardiovasc Imaging2023;39:667-76

[32] Räber L,Koskinas KC.Clinical use of intracoronary imaging. Part 1: guidance and optimization of coronary interventions. An expert consensus document of the European Association of Percutaneous Cardiovascular Interventions.Eur Heart J2018;39:3281-300

[33] Hennessey B,Mejía-Rentería H,Escaned J.Contemporary use of coronary computed tomography angiography in the planning of percutaneous coronary intervention.Int J Cardiovasc Imaging2020;36:2441-59

[34] Kobayashi Y,Kume T.Impact of target lesion coronary calcification on stent expansion.Circ J2014;78:2209-14

[35] Fujino A,Lee T.Predictors of calcium fracture derived from balloon angioplasty and its effect on stent expansion assessed by optical coherence tomography.JACC Cardiovasc Interv2018;11:1015-7

[36] Maejima N,Saka K.Relationship between thickness of calcium on optical coherence tomography and crack formation after balloon dilatation in calcified plaque requiring rotational atherectomy.Circ J2016;80:1413-9

[37] Tearney GJ,Akasaka T.Consensus standards for acquisition, measurement, and reporting of intravascular optical coherence tomography studies: a report from the international working group for intravascular optical coherence tomography standardization and validation.J Am Coll Cardiol2012;59:1058-72

[38] Mario C, Ramasami N. Techniques to enhance guide catheter support.Catheter Cardiovasc Interv2008;72:505-12

[39] Kassimis G,Kontogiannis N.How should we treat heavily calcified coronary artery disease in contemporary practice? From atherectomy to intravascular lithotripsy.Cardiovasc Revasc Med2019;20:1172-83

[40] Costopoulos C,Colombo A.Tools and techniques clinical: percutaneous intervention of calcific coronary lesions.EuroIntervention2014;9:1124-6

[41] Okura H,Shimodozono S.Mechanisms of acute lumen gain following cutting balloon angioplasty in calcified and noncalcified lesions: an intravascular ultrasound study.Catheter Cardiovasc Interv2002;57:429-36

[42] Tang Z,Su SP.Cutting-balloon angioplasty before drug-eluting stent implantation for the treatment of severely calcified coronary lesions.J Geriatr Cardiol2014;11:44-9

[43] Mangieri A,Castriota F.Cutting balloon to optimize predilation for stent implantation: the COPS randomized trial.Catheter Cardiovasc Interv2023;101:798-805

[44] Ikenaga H,Kihara Y.Optical coherence tomography findings after scoring balloon dilatation.Rev Esp Cardiol2015;68:1022

[45] Benezet J,Cubero JM,Fernández-Quero M.Drug-eluting stents following rotational atherectomy for heavily calcified coronary lesions: long-term clinical outcomes.J Invasive Cardiol2011;23:28-32

[46] Fourrier JL,Auth DC,Gommeaux A.Percutaneous coronary rotational angioplasty in humans: preliminary report.J Am Coll Cardiol1989;14:1278-82

[47] Abdel-Wahab M,Büttner JH.High-speed rotational atherectomy before paclitaxel-eluting stent implantation in complex calcified coronary lesions: the randomized ROTAXUS (rotational atherectomy prior to taxus stent treatment for complex native coronary artery disease) trial.JACC Cardiovasc Interv2013;6:10-9

[48] de Ribamar Costa J Jr,Carlier SG.Nonrandomized comparison of coronary stenting under intravascular ultrasound guidance of direct stenting without predilation versus conventional predilation with a semi-compliant balloon versus predilation with a new scoring balloon.Am J Cardiol2007;100:812-7

[49] Otsuka Y,Imoto Y.Prolonged inflation technique using a scoring balloon for severe calcified lesion.Int Heart J2017;58:982-7

[50] Dayco JS,Almas T.Major Complications and failure modes of the angiosculpt scoring balloon catheter: analysis of the MAUDE database.Curr Probl Cardiol2023;48:101557

[51] Secco GG,Mattesini A.Very high-pressure dilatation for undilatable coronary lesions: indications and results with a new dedicated balloon.EuroIntervention2016;12:359-65

[52] Secco GG,Parisi R.Clinical experience with very high-pressure dilatation for resistant coronary lesions.Cardiovasc Revasc Med2019;20:1083-7

[53] Rheude T,Richardt G.Super high-pressure balloon versus scoring balloon to prepare severely calcified coronary lesions: the ISAR-CALC randomised trial.EuroIntervention2021;17:481-8 PMCID:PMC9724952

[54] Scalamogna M,Mashayekhi K.Randomized ComparIson of strategies to PrepAre SeveRely CALCified coronary lesions 2: design and rationale of the ISAR-CALC 2 trial.Cardiovasc Revasc Med2023;49:22-7

[55] Pinilla-Echeverri N,Hillani A.Treatment of calcified lesions using a dedicated super-high pressure balloon: multicenter optical coherence tomography registry.Cardiovasc Revasc Med2023;52:49-58

[56] Kawamoto H,Ruparelia N.In-hospital and midterm clinical outcomes of rotational atherectomy followed by stent implantation: the ROTATE multicentre registry.EuroIntervention2016;12:1448-56

[57] Neumann FJ,Ahlsson A.2018 ESC/EACTS guidelines on myocardial revascularization.Eur Heart J2019;40:87-165

[58] Kini AS,Pena J.Optical coherence tomography assessment of the mechanistic effects of rotational and orbital atherectomy in severely calcified coronary lesions.Catheter Cardiovasc Interv2015;86:1024-32

[59] Kurogi K,Ikebe S.Optical coherence tomography-versus intravascular ultrasound-guided stent expansion in calcified lesions.Cardiovasc Interv Ther2022;37:312-23

[60] de Waha S,Büttner HJ.Rotational atherectomy before paclitaxel-eluting stent implantation in complex calcified coronary lesions: two-year clinical outcome of the randomized ROTAXUS trial.Catheter Cardiovasc Interv2016;87:691-700

[61] Abdel-Wahab M,Byrne RA.High-speed rotational atherectomy versus modified balloons prior to drug-eluting stent implantation in severely calcified coronary lesions.Circ Cardiovasc Interv2018;11:e007415

[62] Allali A,Abdel-Wahab M.Combined rotational atherectomy and cutting balloon angioplasty prior to drug-eluting stent implantation in severely calcified coronary lesions: the PREPARE-CALC-COMBO study.Catheter Cardiovasc Interv2022;100:979-89

[63] Furuichi S,Godino C.Rotational atherectomy followed by drug-eluting stent implantation in calcified coronary lesions.EuroIntervention2009;5:370-4

[64] Vaquerizo B,Miranda F.Aggressive plaque modification with rotational atherectomy and/or cutting balloon before drug-eluting stent implantation for the treatment of calcified coronary lesions.J Interv Cardiol2010;23:240-8

[65] Naito R,Wada H.Comparison of long-term clinical outcomes between sirolimus-eluting stents and paclitaxel-eluting stents following rotational atherectomy.Int Heart J2012;53:149-53

[66] Sakakura K,Taniguchi Y.The incidence of slow flow after rotational atherectomy of calcified coronary arteries: a randomized study of low speed versus high speed.Catheter Cardiovasc Interv2017;89:832-40

[67] Jinnouchi H,Taniguchi Y.Intravascular ultrasound-factors associated with slow flow following rotational atherectomy in heavily calcified coronary artery.Sci Rep2022;12:5674 PMCID:PMC8983755

[68] Sulimov DS,Toelg R,Geist V.Stuck rotablator: the nightmare of rotational atherectomy.EuroIntervention2013;9:251-8

[69] Medda M,Bande M.Protected rotational atherectomy with double-guiding catheter technique for unprotected distal left main.J Am Coll Cardiol Interv2019;12:e27-9.

[70] Barbato E,Dardas P.European expert consensus on rotational atherectomy.EuroIntervention2015;11:30-6.

[71] Barbato E,Milkas A,Azzalini L.State of the art: evolving concepts in the treatment of heavily calcified and undilatable coronary stenoses - from debulking to plaque modification, a 40-year-long journey.EuroIntervention2017;13:696-705

[72] Yamamoto MH,Karimi Galougahi K.Mechanisms of orbital versus rotational atherectomy plaque modification in severely calcified lesions assessed by optical coherence tomography.JACC Cardiovasc Interv2017;10:2584-6

[73] Shipman JN. Orbital atherectomy. Treasure Island, FL: StatPearls Publishing. 2023. Available from: http://www.ncbi.nlm.nih.gov/books/NBK563144/ [Last accessed on 26 Feb 2024]

[74] Sotomi Y,Shlofmitz RA.Quantification by optical coherence tomography imaging of the ablation volume obtained with the orbital atherectomy system in calcified coronary lesions.EuroIntervention2016;12:1126-34

[75] Parikh K,Choksi N,Chambers J.Safety and feasibility of orbital atherectomy for the treatment of calcified coronary lesions: the ORBIT I trial.Catheter Cardiovasc Interv2013;81:1134-9

[76] Shlofmitz E,Lee M.Orbital atherectomy for the treatment of severely calcified coronary lesions: evidence, technique, and best practices.Expert Rev Med Devic2017;14:867-79

[77] Sotomi Y,Colombo A,Onuma Y.Patient selection and procedural considerations for coronary orbital atherectomy system.Interv Cardiol2016;11:33-8 PMCID:PMC5808671

[78] Panchal HB,Kirtane AJ.Microcatheter-protected orbital atherectomy for severely calcified bifurcation coronary artery disease with single-guiding catheter technique.JACC Cardiovasc Interv2020;13:e1-3

[79] Redfors B,Saito S.Novel micro crown orbital atherectomy for severe lesion calcification: coronary orbital atherectomy system study (COAST).Circ Cardiovasc Interv2020;13:e008993 PMCID:PMC7434218

[80] Martinsen BJ,Saito S.Japan-USA orbital atherectomy for calcific coronary lesions: COAST study, harmonization by doing proof-of-concept.Cardiovasc Revasc Med2022;37:112-7

[81] Chambers JW,Himmelstein SI.Pivotal trial to evaluate the safety and efficacy of the orbital atherectomy system in treating de novo, severely calcified coronary lesions (ORBIT II).JACC Cardiovasc Interv2014;7:510-8

[82] Généreux P,Kim CY.Orbital atherectomy for treating de novo severely calcified coronary narrowing (1-year results from the pivotal ORBIT II trial).Am J Cardiol2015;115:1685-90

[83] Bhatt P,Patel A.Long-term safety and performance of the orbital atherectomy system for treating calcified coronary artery lesions: 5-year follow-up in the ORBIT I trial.Cardiovasc Revasc Med2015;16:213-6

[84] Yap LB,Navin S,Jeyamalar R.Intravascular imaging-guided treatment of severe coronary artery calcification with orbital atherectomy: a prospective single-centre registry.Med J Malaysia2023;78:7-13

[85] Sandhyavenu H,Badu I.Outcomes of intravascular imaging in orbital atherectomy; insight from the national readmissions database.Curr Probl Cardiol2023;48:101475

[86] Généreux P,Kandzari DE.Randomized evaluation of vessel preparation with orbital atherectomy prior to drug-eluting stent implantation in severely calcified coronary artery lesions: design and rationale of the ECLIPSE trial.Am Heart J2022;249:1-11

[87] Baumbach A,Fleck E.Acute complications of excimer laser coronary angioplasty: a detailed analysis of multicenter results.J Am Coll Cardiol1994;23:1305-13

[88] Deckelbaum LI,Bittl .Effect of intracoronary saline infusion on dissection during excimer laser coronary angioplasty: a randomized trial. The percutaneous excimer laser coronary angioplasty (PELCA) investigators.J Am Coll Cardiol1995;26:1264-9

[89] Bilodeau L,Taeymans Y,Taylor K.Novel use of a high-energy excimer laser catheter for calcified and complex coronary artery lesions.Catheter Cardiovasc Interv2004;62:155-61

[90] Egred M.RASER angioplasty.Catheter Cardiovasc Interv2012;79:1009-12

[91] Badr S,Dvir D.The state of the excimer laser for coronary intervention in the drug-eluting stent era.Cardiovasc Revasc Med2013;14:93-8

[92] Alfonso F,Giacoppo D,Byrne RA.Management of in-stent restenosis.EuroIntervention2022;18:e103-23. PMCID:PMC9904384

[93] Ben-Dor I,Pichard AD.The use of excimer laser for complex coronary artery lesions.Cardiovasc Revasc Med2011;12:69.e1-8

[94] Fretz EB,Hilton JD.Initial experience with a low profile, high energy excimer laser catheter for heavily calcified coronary lesion debulking: parameters and results of first seven human case experiences.J Interv Cardiol2001;14:433-7

[95] Rawlins J,Green M.Optical coherence tomography following percutaneous coronary intervention with excimer laser coronary atherectomy.Cardiovasc Revasc Med2014;15:29-34

[96] Gemma D,Sánchez-Recalde Á.Effects of excimer laser coronary atherectomy assessed by OCT.Rev Esp Cardiol2017;70:116

[97] Ambrosini V,Laurenzano E.Early outcome of high energy laser (Excimer) facilitated coronary angioplasty ON hARD and complex calcified and balloOn-resistant coronary lesions: LEONARDO Study.Cardiovasc Revasc Med2015;16:141-6

[98] Ojeda S,Suárez de Lezo J.Excimer laser coronary atherectomy for uncrossable coronary lesions. A multicenter registry.Catheter Cardiovasc Interv2021;98:1241-9

[99] Kereiakes DJ,Ben-Yehuda O,Alexander B.Evaluation of safety and efficacy of coronary intravascular lithotripsy for treatment of severely calcified coronary stenoses: design and rationale for the disrupt CAD III trial.Am Heart J2020;225:10-8

[100] Brinton TJ,Hill JM.Feasibility of shockwave coronary intravascular lithotripsy for the treatment of calcified coronary stenoses.Circulation2019;139:834-6

[101] Yeoh J.Intracoronary lithotripsy for the treatment of calcified plaque.Interv Cardiol Clin2019;8:411-24

[102] Ali ZA,Hill JM.Optical coherence tomography characterization of coronary lithoplasty for treatment of calcified lesions: first description.JACC Cardiovasc Imaging2017;10:897-906

[103] Ali ZA,Escaned J.Safety and effectiveness of coronary intravascular lithotripsy for treatment of severely calcified coronary stenoses: the disrupt CAD II study.Circ Cardiovasc Interv2019;12:e008434

[104] Saito S,Takahashi A.Intravascular lithotripsy for vessel preparation in severely calcified coronary arteries prior to stent placement - primary outcomes from the Japanese disrupt CAD IV study.Circ J2021;85:826-33

[105] Emori H,Kuriyama N.Calcium fracture after intravascular lithotripsy as assessed with optical coherence tomography.Circ J2023;87:799-805

[106] Kawai K,Hakoma JY.CRT-100.41 histology, OCT, and Micro-CT evaluation of coronary calcification in atherosclerotic cadaver arteries treated with intravascular lithotripsy.JACC Cardiovasc Interv2023;16:S2

[107] Hofmann FJ,Blachutzik F.First case report of fully robotically assisted lithotripsy in heavily calcified left main stenosis.Eur Heart J Case Rep2023;7:ytac427 PMCID:PMC9856338

[108] Sheikh AS,Abdul F,Sharma V.Intravascular lithotripsy for severe coronary calcification: a systematic review.Minerva Cardiol Angiol2023;71:643-52

[109] Alfonso F,Antuña P.Coronary lithoplasty for the treatment of undilatable calcified de novo and in-stent restenosis lesions.JACC Cardiovasc Interv2019;12:497-9

[110] Huisman J,Kok MM.Two-year outcome after treatment of severely calcified lesions with newer-generation drug-eluting stents in acute coronary syndromes: a patient-level pooled analysis from TWENTE and DUTCH PEERS.J Cardiol2017;69:660-5

[111] Sugiyama T,Fracassi F.Calcified plaques in patients with acute coronary syndromes.JACC Cardiovasc Interv2019;12:531-40

[112] Torii S,Otsuka F.Eruptive calcified nodules as a potential mechanism of acute coronary thrombosis and sudden death.J Am Coll Cardiol2021;77:1599-611

[113] Alfonso F,Bastante T,Benedicto A.In-Stent restenosis caused by a calcified nodule: a novel pattern of neoatherosclerosis.Can J Cardiol2016;32:830.e1-3

[114] Mori H,Atkinson JB,Narula J.Calcified nodule: an early and late cause of in-stent failure.JACC Cardiovasc Interv2016;9:e125-6

[115] Furuse E,Tajiri M,Shimizu W.In-stent restenosis caused by calcified nodule 11 years after paclitaxel eluting stent implantation treated with drug-coated balloon following rotational atherectomy.Cardiovasc Interv Ther2020;35:302-3

[116] Nagata T,Katsura A.Optical coherence tomography factors for adverse events in patients with severe coronary calcification.Int J Cardiol2023;376:28-34

[117] Pengchata P,Wongsawangkit N,Wongpraparut N.Characteristics and pattern of calcified nodule and/or nodular calcification detected by intravascular ultrasound on the device-oriented composite endpoint (DoCE) in patients with heavily calcified lesions who underwent rotational atherectomy-assisted percutaneous coronary intervention.J Interv Cardiol2023;2023:6456695 PMCID:PMC9884160

[118] Allali A,Toelg R.High-speed rotational atherectomy versus modified balloons for plaque preparation of severely calcified coronary lesions: two-year outcomes of the randomised PREPARE-CALC trial.EuroIntervention2023;18:e1365-7 PMCID:PMC10068860

[119] Han FJ,Zheng XZ.Efficacy of intravascular ultrasound-guided rotational atherectomy combined with cutting balloon for pretreatment of severe coronary artery calcified lesions.Nan Fang Yi Ke Da Xue Xue Bao2021;41:1044-9

[120] McLaughlin TJ,Kumar G.First United States experience with rota-shock: a case series.Cardiovasc Revasc Med2022;40S:209-13

[121] Buono A,Choudhury A.“RotaTripsy” for severe calcified coronary artery lesions: insights from a real-world multicenter cohort.Cardiovasc Revasc Med2022;37:78-81

[122] Dwivedi P,Kumar KR.Efficacy and safety of an upfront RotaTripsy strategy in the treatment of de novo and in-stent restenosis cases.J Invasive Cardiol2023;35:E70-4

[123] Wong B,So CY.Synergistic coronary artery calcium modification with combined atherectomy and intravascular lithotripsy.J Invasive Cardiol2023;35:E128-35

[124] Jurado-Román A,Moreno R.ELCA-tripsy: combination of laser and lithotripsy for severely calcified lesions.J Invasive Cardiol2021;33:E754-5

[125] Yamamoto H,Yoshida C.Combined orbital and rotational atherectomy for severe nodular calcification at curved arteries.Circ J2023;87:582