From single debulking techniques to combined approaches: a review of bailout strategies in heavily calcified coronary lesions

Abstract

The increase in the average age of the population leads to an inevitable increase in demand for coronary intervention in elderly patients with more comorbidities, often carriers of coronary calcifications. Calcific lesions present a major challenge in Percutaneous Coronary Interventions, often requiring debulking techniques for successful lesion preparation. In some cases, the combined use of “dedicated” devices is essential. Some imaging-based algorithms have been established to guide the stepwise treatment of severe angiographic calcification by evaluating the calcium burden in terms of its circumferential extension, length, and thickness. Mild angiographic calcifications do not require an atherectomy strategy. Moderate and severe angiographic calcifications generally require debulking techniques. Currently, practice guidelines recommend the use of rotational atherectomy to prepare heavily calcified lesions that cannot be crossed using a balloon or adequately dilated before planned stenting (bailout situations). However, the evaluation of the plaques, as well as the characteristics of the patient, should be considered when choosing the most appropriate debulking system, and sometimes a combination of different techniques may be necessary. Therefore, understanding the various debulking systems and the possible combinations of these can be crucial for optimizing the procedural outcome.

Keywords

Percutaneous coronary interventions / calcific lesions / rotablator system / orbital atherectomy / intravascular lithotripsy system / excimer laser coronary atherectomy

References

[1] van Soest G,Gonzalo N.Imaging atherosclerotic plaque composition with intracoronary optical coherence tomography.Neth Heart J2009;17:448-50 PMCID:PMC2779484

[2] Dini CS,Ristalli F,Hamiti B.Contemporary approach to heavily calcified coronary lesions.Interv Cardiol2019;14:154-63 PMCID:PMC6918474

[3] Torii S,Sakamoto A.Vascular responses to coronary calcification following implantation of newer-generation drug-eluting stents in humans: impact on healing.Eur Heart J2020;41:786-96.

[4] Onnis C,Kawai K.Coronary artery calcification: current concepts and clinical implications.Circulation2024;149:251-66 PMCID:PMC10794033

[5] Huisman J,Kok MM.Impact of severe lesion calcification on clinical outcome of patients with stable angina, treated with newer generation permanent polymer-coated drug-eluting stents: a patient-level pooled analysis from TWENTE and DUTCH PEERS (TWENTE II).Am Heart J2016;175:121-9

[6] Généreux P,Witzenbichler B.Two-year outcomes after percutaneous coronary intervention of calcified lesions with drug-eluting stents.Int J Cardiol2017;231:61-7

[7] Rheude T,Allali A.Rotational atherectomy or balloon-based techniques to prepare severely calcified coronary lesions.JACC Cardiovasc Interv2022;15:1864-74

[8] Andò G,Niccoli G.a nome del Gruppo di Studio “Cardiologia Interventistica” della Società Italiana di CardiologiaEvaluation and percutaneous treatment of severely calcified coronary lesions.G Ital Cardiol2021;22:480-9

[9] Fujino A,Matsumura M.A new optical coherence tomography-based calcium scoring system to predict stent underexpansion.EuroIntervention2018;13:e2182-9

[10] Kang DY,Yun SC.OCTIVUS InvestigatorsOptical coherence tomography-guided or intravascular ultrasound-guided percutaneous coronary intervention: the OCTIVUS randomized clinical trial.Circulation2023;148:1195-206

[11] Kang DY,Yun SC.OCTIVUS InvestigatorsGuiding intervention for complex coronary lesions by optical coherence tomography or intravascular ultrasound.J Am Coll Cardiol2024;83:401-13

[12] Burzotta F,Lassen JF.Percutaneous coronary intervention for bifurcation coronary lesions using optimised angiographic guidance: the 18th consensus document from the European Bifurcation Club.EuroIntervention2024;20:e915-26 PMCID:PMC11285041

[13] Barbato E,Abdel-Wahab M.Management strategies for heavily calcified coronary stenoses: an EAPCI clinical consensus statement in collaboration with the EURO4C-PCR group.Eur Heart J2023;44:4340-56

[14] Kobayashi N,Yamawaki M.Optical coherence tomography-guided versus intravascular ultrasound-guided rotational atherectomy in patients with calcified coronary lesions.EuroIntervention2020;16:e313-21

[15] Tovar Forero MN,van Mieghem NM.Coronary lithoplasty: a novel treatment for stent underexpansion.Eur Heart J2019;40:221

[16] Ali ZA,Hill JM.Intravascular lithotripsy for treatment of stent underexpansion secondary to severe coronary calcification.Eur Heart J2020;41:485-6

[17] Nagaraja V,Khoo C.Intravascular lithotripsy for stent underexpansion despite utilization of rotational atherectomy for plaque modification.Cardiovasc Revasc Med2020;21:147-8

[18] Caracciolo A,Laterra G.Antithrombotic therapy for percutaneous cardiovascular interventions: from coronary artery disease to structural heart interventions.J Clin Med2019;8:2016 PMCID:PMC6912795

[19] Achim A,Krivoshei L.In vitro effect of intravascular lithotripsy on the polymer of a drug-eluting stent.EuroIntervention2022;18:e333-4 PMCID:PMC9980395

[20] Dattilo G,Correale M.Trend of perceived quality of life and functional capacity in outpatients with chronic heart failure and in treatment with sacubitril/valsartan: a real-life experience.Minerva Cardiol Angiol2022;70:555-62

[21] Cuculi F,Zasada W.Performing percutaneous coronary interventions with predilatation using non-compliant balloons at high-pressure versus conventional semi-compliant balloons: insights from two randomised studies using optical coherence tomography.Open Heart2020;7:e001204 PMCID:PMC6999685

[22] Caminiti R,Ielasi A.>Drug-coated balloon versus drug-eluting stent for treating de novo large vessel coronary artery disease: a systematic review and meta-analysis of 13 studies involving 2888 patients. Clin Res Cardiol. 2024.

[23] Lhermusier T,Bataille V.TIcagrelor in rotational atherectomy to reduce TROPonin enhancement: the TIRATROP study, a randomized controlled trial.J Clin Med2023;12:1445 PMCID:PMC9964861

[24] Díaz JF,Cardenal R,Sanghvi A.Extremely high-pressure dilation with a new noncompliant balloon.Tex Heart Inst J2012;39:635-8. PMCID:PMC3461667

[25] Mauri L,Weiner BH.Cutting balloon angioplasty for the prevention of restenosis: results of the cutting balloon global randomized trial.Am J Cardiol2002;90:1079-83

[26] Schmidt T,Meincke F,Kuck KH.Safety and efficacy of lesion preparation with the AngioSculpt Scoring Balloon in left main interventions: the ALSTER left main registry.EuroIntervention2016;11:1346-54

[27] Fonseca A,Abizaid A.Intravascular ultrasound assessment of the novel AngioSculpt scoring balloon catheter for the treatment of complex coronary lesions.J Invasive Cardiol2008;20:21-7.

[28] Mashayekhi KA,Werner GS.Contemporary issues of percutaneous coronary intervention in heavily calcified chronic total occlusions: an expert review from the European CTO Club.EuroIntervention2023;19:e113-22 PMCID:PMC10240733

[29] Barbato E,Dardas P.European Association of Percutaneous Cardiovascular InterventionsEuropean expert consensus on rotational atherectomy.EuroIntervention2015;11:30-6

[30] Lawton JS,Bangalore S.2021 ACC/AHA/SCAI Guideline for coronary artery revascularization: executive summary: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines.JACC2022;79:197-215

[31] Galassi AR,Werner GS.Evaluation and management of patients with coronary chronic total occlusions considered for revascularisation. A clinical consensus statement of the European Association of Percutaneous Cardiovascular Interventions (EAPCI) of the ESC, the European Association of Cardiovascular Imaging (EACVI) of the ESC, and the ESC Working Group on Cardiovascular Surgery.EuroIntervention2024;20:e174-84 PMCID:PMC10836390

[32] Bacmeister L,Sobolewska K.Planned versus unplanned rotational atherectomy for plaque modification in severely calcified coronary lesions.Clin Res Cardiol2023;112:1252-62 PMCID:PMC10449691

[33] 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

[34] Jinnouchi H,Shinozaki T.Two-year clinical outcomes of newer-generation drug-eluting stent implantation following rotational atherectomy for heavily calcified lesions.Circ J2015;79:1938-43

[35] Abdel-Wahab M,Joachim Büttner H.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

[36] 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

[37] 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

[38] 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

[39] 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

[40] 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

[41] 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

[42] Kirtane AJ,Lewis B.ECLIPSE InvestigatorsOrbital atherectomy versus balloon angioplasty before drug-eluting stent implantation in severely calcified lesions eligible for both treatment strategies (ECLIPSE): a multicentre, open-label, randomised trial.Lancet2025;405:1240-51

[43] Okamoto N,Nohara H.Direct comparison of rotational vs orbital atherectomy for calcified lesions guided by optical coherence tomography.JACC Cardiovasc Interv2023;16:2125-36

[44] Daemen J.The coronary intravascular lithotripsy system.Interv Cardiol2019;14:174-81 PMCID:PMC6918618

[45] 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

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

[47] Hill JM,Shlofmitz RA.Disrupt CAD III InvestigatorsIntravascular lithotripsy for treatment of severely calcified coronary artery disease.J Am Coll Cardiol2020;76:2635-46

[48] Sintek M,Bach R.Excimer laser coronary angioplasty in coronary lesions: use and safety from the NCDR/CATH PCI registry.Circ Cardiovasc Interv2021;14:e010061

[49] Vizzari G,Ielasi A.Contrast-enhanced excimer laser stepwise approach during PCI for resistant coronary lesions.Catheter Cardiovasc Interv2024;104:220-6

[50] Cobarro L,Tébar-márquez D.Excimer laser coronary atherectomy in severely calcified lesions: time to bust the myth.REC Interv Cardiol2024;

[51] Caminiti R,Parlavecchio A.A Systematic review and meta-analysis including 354 patients from 13 studies of intravascular lithotripsy for the treatment of underexpanded coronary stents.Am J Cardiol2023;205:223-30

[52] Tehrani S,Achan V.Changing paradigm for treatment of heavily calcified coronary artery disease. A complementary role of rotational atherectomy and intravascular lithotripsy with shockwave balloon: a case report.Eur Heart J Case Rep2021;5:ytaa456 PMCID:PMC7898579

[53] Blachutzik F,Blachutzik M.ROTAshock Investigators. Comparison of interventional treatment options for coronary calcified nodules: a sub-analysis of the ROTA.shock trial.Cardiovasc Revasc Med2024;68:37-42

[54] Aznaouridis K,Masoura C,Tousoulis D.Rotatripsy: a hybrid “drill and disrupt” approach for treating heavily calcified coronary lesions.J Invasive Cardiol2020;32:E175

[55] Jurado-Román A,Galeote G,Moreno R.RotaTripsy: combination of rotational atherectomy and intravascular lithotripsy for the treatment of severely calcified lesions.JACC Cardiovasc Interv2019;12:e127-9

[56] Ielasi A,De Blasio G.“Rota-Tripsy”: a successful combined approach for the treatment of a long and heavily calcified coronary lesion.Cardiovasc Revasc Med2020;21:152-4

[57] Sardella G,Leone PP.Coronary lithotripsy as elective or bail-out strategy after rotational atherectomy in the rota-shock registry.Am J Cardiol2023;198:1-8

[58] Cui F,Yang P.Rota-tripsy or step-up-approach rotational atherectomy for severe coronary artery calcification treatment: a comparative effectiveness study.Sci Rep2024;14:29866 PMCID:PMC11611902

[59] Protty MB,Farooq V.Combined use of rotational and excimer lASER coronary atherectomy (RASER) during complex coronary angioplasty-an analysis of cases (2006-2016) from the British Cardiovascular Intervention Society database.Catheter Cardiovasc Interv2021;97:E911-8

[60] Sharma SK,Vogel B.Rotational atherectomy combined with cutting balloon to optimise stent expansion in calcified lesions: the ROTA-CUT randomised trial.EuroIntervention2024;20:75-84 PMCID:PMC10756220

[61] 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

[62] Włodarczak S,Furtan Ł.Orbital-tripsy - orbital atherectomy facilitated by shockwave intravascular lithotripsy: novel bailout strategy in percutaneous coronary intervention in heavily calcified coronary lesions.Kardiol Pol2023;81:296-7

[63] Yarusi BB,Hussain S.Combined coronary orbital atherectomy and intravascular lithotripsy for the treatment of severely calcified coronary stenoses: the first case series.J Invasive Cardiol2022;34:E210-7

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

[65] Venuti G,Tamburino C.Coronary lithotripsy for failed rotational atherectomy, cutting balloon, scoring balloon, and ultra-high-pressure non-compliant balloon.Catheter Cardiovasc Interv2019;94:E111-5

[66] Jurado-Román A,Rivero-Santana B.Rotational atherectomy, lithotripsy, or laser for calcified coronary stenosis: the ROLLER COASTR-EPIC22 Trial.JACC Cardiovasc Interv2025;18:606-18

[67] Lehker A.Coronary calcium risk score and cardiovascular risk.Curr Vasc Pharmacol2021;19:280-4

[68] Laterra G,Reddavid C.Evaluation and management of coronary artery disease in transcatheter aortic valve implantation candidates with severe aortic stenosis and coronary artery disease: technology and techniques.Expert Rev Med Devices2024;21:915-25

[69] Rheude T,Ribichini FL.Comparison of different percutaneous revascularisation timing strategies in patients undergoing transcatheter aortic valve implantation.EuroIntervention2023;19:589-99