SCAI Expert Consensus Statement on the Management of Calcified Coronary Lesions

Comparison of Procedural and Clinical Outcomes of Angiography- Versus Imaging-Guided Percutaneous Coronary Intervention With Intravascular Lithotripsy

BACKGROUND

Intravascular lithotripsy (IVL) is an innovative treatment for coronary artery calcification (CAC).

AIMS

This study aimed to compare procedural and clinical outcomes of intracoronary imaging (ICI)-guided percutaneous coronary intervention (PCI) versus angiography-guided PCI with IVL in patients with CAC.

METHODS

A total of 509 patients were analyzed from the BENELUX-IVL registry (May 2019 to September 2024). Angiography-guided PCI with IVL was defined as therapy under solely fluoroscopic guidance. ICI-guided PCI with IVL was defined as PCI with IVL and concomitant use of ICI for procedural guidance either pre- and/or post-IVL. The primary endpoint was procedural success, defined as Thrombolysis In Myocardial Infarction (TIMI) 3 flow, residual stenosis < 30%, and absence of in-hospital major adverse cardiovascular events (MACE). Safety endpoints included procedural complications and MACE up to 2-year follow-up.

RESULTS

A total of 537 lesions were treated with IVL: 252 (46.9%) angiography-guided and 285 (53.1%) ICI-guided. The ICI-guided group had more complex lesions, with higher rates of aorto-ostial (20.2% vs. 30.9%; p = 0.005), chronic total occlusions (2.8% vs. 12.3%; p = 0.001), and long-segment lesions (58.7% vs. 69.5%; p = 0.009). Procedural success rates were comparable between groups (88.7% vs. 89.7%; p = 0.71), as were device success (97.9% vs. 97.4%; p = 0.72) and technical success (89.1% vs. 91.5%; p = 0.35). MACE rates remained similar at all time points up to 2-year follow-up (p > 0.05).

CONCLUSION

Procedural success was comparable between angiography-guided and ICI-guided PCI with IVL, despite greater lesion complexity in the ICI-guided group. Complication rates were similar, with no significant differences in MACE or mortality at long-term follow-up.

Drug coated balloons in percutaneous coronary intervention: how can computational modelling help inform evolving clinical practice?

Drug-coated balloons (DCB) represent an emerging therapeutic alternative to drug-eluting stents (DES) for the treatment of coronary artery disease (CAD). Among the key advantages of DCB over DES are the absence of a permanent structure in the vessel and the potential for fast and homogeneous drug delivery. While DCB were first introduced for treatment of in-stent restenosis (ISR), their potential wider use in percutaneous coronary intervention (PCI) has recently been explored in several randomized clinical trials, including for treatment of de novo lesions. Moreover, new hybrid techniques that combine DES and DCB are being investigated to more effectively tackle complex cases. Despite the growing interest in DCB within the clinical community, the mechanisms of drug exchange and the interactions between the balloon, the polymeric coating and the vessel wall are yet to be fully understood. It is, therefore, perhaps surprising that the number of computational (in silico) models developed to study interventions involving these devices is small, especially given the mechanistic understanding that has been gained from computational studies of DES procedures over the last two decades. In this paper, we discuss the current and emerging clinical approaches for DCB use in PCI and review the computational models that have been developed thus far, underlining the potential challenges and opportunities in integrating in silico models of DCB into clinical practice.

OCT vs Angiography for Guidance of Percutaneous Coronary Intervention of Calcified Lesions: The CALIPSO Randomized Clinical Trial

Importance

The use of intravascular imaging for calcified plaque characterization and preparation has been advocated over conventional methods to improve percutaneous coronary intervention (PCI) outcomes, but this approach has never been evaluated.

Objective

To determine if optical coherence tomography (OCT) is superior to angiography for calcified lesions PCI guidance.

Design, Setting, and Participants

The CALIPSO (Calcified Lesion Intervention Planning Steered by OCT) trial was a prospective, multicenter, open-label, randomized clinical trial that included patients with stable moderate to severe calcified coronary lesions on coronary angiography scheduled for PCI. The trial was conducted at 12 sites in France between December 2021 and June 2023, and data were analyzed from December 2023 to April 2024.

Intervention

After diagnostic coronary angiography, eligible patients were randomly assigned in a 1:1 ratio to receive OCT-guided PCI or angiography-guided PCI. In the OCT group, the procedures were guided by OCT analysis and predefined standardized management algorithms. Patients from both arms had control post-PCI OCT analysis after procedure completion for primary end point measurement.

Main Outcomes and Measures

The primary end point was the minimal stent area (MSA) measured by OCT in both groups. Secondary key safety end points included periprocedural myocardial infarction, radiation dose, contrast medium volume, and procedure duration.

Results

A total of 143 patients were randomized, and 134 were included in the final analysis (65 in the OCT group and 69 in the angiography group). Median (IQR) patient age was 73.0 (66.0-78.0) years, and 25 patients (18.7%) were female. The baseline characteristics of the groups were comparable, but the use of intravascular lithotripsy was more frequent in the OCT arm (30 patients [46%] vs 8 patients [12%]; P < .001). The final median (IQR) MSA was larger in the OCT group than in the angiography group (6.5 [5.5-8.1] mm2 vs 5.0 [4.1-6.1] mm2; P < .001). There was no difference in periprocedural complications incidence, contrast medium volume, or procedure duration between groups.

Conclusions and Relevance

The CALIPSO randomized clinical trial showed that OCT guidance associated with predefined algorithmic management achieved better stent implantation results than angiography guidance in patients with calcified lesions PCI, without any additional safety concern.

Trial Registration

ClinicalTrials.gov Identifier: NCT05301218.

'RotaShock' - A Revolution in Calcium Modification: Long-term Follow-up from a Single High-volume Centre

Background

Rotational atherectomy (RA) and intravascular lithotripsy (IVL) are well-established technologies for modification of coronary calcification. Given their contrasting mechanisms of action, there has been interest in whether the use of these devices in conjunction could potentially be synergistic and offer improved procedural results. The aim of this study was therefore to evaluate the efficacy, procedural safety and long-term outcomes of combining RA and IVL, termed 'RotaShock' (RSK), for the treatment of severe coronary calcification.

Methods

A single- centre retrospective analysis was carried out of consecutive patients treated with an RSK strategy for coronary calcification from January 2019 until September 2022. Baseline demographics, comorbidity details, details of the percutaneous coronary intervention procedure, angiographic and/or intracoronary imaging (ICI) results and presence of target vessel revascularisation or mortality were recorded.

Results

A total of 36 patients were treated with RSK; the majority of patients were male (n=29; 80.6%) and the median age was 75 years (IQR 70-79 years). The majority of cases involved treating the left anterior descending artery (63.4%) but one-third involved percutaneous coronary intervention to the left main coronary artery. The vast majority of cases were guided by ICI (88.9%) and were performed through radial access (80.6%). In patients with ICI available for analysis, the median minimum stent area was 7.7 mm2 (IQR 6.2-10.0 mm2). There were two access site complications but no other periprocedural complications. The median follow-up was 942 days (IQR 645-1,306 days). Despite the high complexity of lesions treated, follow-up identified only two cases of target vessel revascularisation. There were five cases of non-adjudicated all-cause mortality.

Conclusion

RSK is an effective and safe strategy for modification of severe coronary calcification, with long-term results suggesting a highly durable result. Further and randomised data are now mandated to evaluate the relative merits of RSK compared with RA or IVL alone.

Calcified Coronary Artery Disease: Pathology, Prevalence, Predictors and Impact on Outcomes

Calcified coronary artery disease is a common clinical finding and is visible angiographically in 25-30% of patients presenting for percutaneous coronary intervention. The presence of coronary calcium, even without coronary artery obstruction, confers an adverse clinical prognosis. Coronary calcium score on CT is additive in predicting risk of cardiovascular events beyond traditional scoring systems. Deposition of calcium in coronary arteries is initiated by the formation of an atherosclerotic plaque. Thereafter, multiple processes and pathways are involved, resulting in initial microcalcifications that coalesce into calcium sheets. Calcified nodules are thought to occur from rupture of these sheets. Calcified coronary stenoses requiring revascularisation result in greater target lesion failure and overall major adverse cardiovascular events than noncalcified lesions, regardless of the mode of revascularisation. Modifying calcium prior to stenting to optimise stent expansion is required and intracoronary imaging can greatly facilitate not only the detection of coronary calcium, but also the confirmation of adequate modification and stent optimisation. In this review, the authors examine the pathophysiology, prevalence, predictors and impact on outcomes of coronary calcium.

Acute Stent Thrombosis Following Reprotrusion of a Calcified Nodule in the Left Main Coronary Artery

Calcified nodule (CN) is a high-risk phenotype of coronary artery calcification that causes in-stent restenosis frequently. Stent thrombosis (ST) is a critical complication following percutaneous coronary intervention, and its onset is associated with severely calcified lesions. However, the association between CN and ST remains unclear. Moreover, while reprotrusion of CNs through the stent strut is not uncommon immediately after stenting, the risk of ST associated with this acute reprotrusion of CNs is not well recognized. We present a case of a 70-year-old female who developed acute ST following reprotrusion of a CN in the left main coronary artery. After the successful stenting to a large CN, a prominent acute protrusion occurred, followed by the acute occlusion of the implanted stent due to massive thrombus formation. This case highlights the importance of careful monitoring for thrombus formation even after good stent expansion, especially when large acute reprotrusion of CNs is observed.

Percutaneous Revascularization of Thrombotic and Calcified Coronary Lesions

Percutaneous coronary intervention (PCI) for thrombotic and heavily calcified coronary artery lesions and occlusions is often hampered by difficulty in wiring the occlusions, restoring antegrade flow, and proceeding to successful stent implantation. Characterization of dynamic anatomical features such as thrombi and the calcium distribution is key to prevent periprocedural complications and long-term adverse events, which are mainly driven by stent underexpansion and malapposition and may prompt in-stent restenosis or stent thrombosis. Therefore, multimodal imaging is a critical step during PCI to better characterize these high-risk lesions and select those in which careful preparation with debulking devices is needed or to guide stent optimization with the aim of improving procedural and long-term clinical outcomes. Hence, obtaining a better understanding of the underlying cause of thrombus formation, imaging the calcium distribution, and thorough planning remain crucial steps in selecting the optimal revascularization strategy for an individual patient. In this review, we summarize current evidence about the prevalence, predictors, and clinical outcomes of "hard-rock" thrombotic lesions treated by PCI, focusing on the value of imaging and physiological assessments performed to guide interventions. Furthermore, we provide an overview of cutting-edge technologies with the aim of facilitating the use of such devices according to specific procedural features.

Management of Stent Underexpansion and Aorto-ostial Lesions

Stent underexpansion (SU) and aorto-ostial lesions (AOL) are challenging conditions commonly faced during clinical practice in the setting of percutaneous coronary interventions. Compared to other interventional settings, both SU and AOL are associated with an increased risk of immediate and late events following percutaneous coronary intervention. Several specific strategies including the systematic use of intracoronary imaging and dedicated techniques for lesions' preparation and calcium debulking have been described. This narrative review summarises the currently available options for the diagnosis and treatment of both SU and AOL, highlighting the potential benefits and limits of each technique in these specific settings.

Multimodal Intravascular Imaging of the Vulnerable Coronary Plaque

Vulnerable coronary plaques are atherosclerotic lesions which, due to their specific phenotype, are prone to plaque rupture and to cause acute coronary syndromes, with subsequent relevant morbidity and mortality. Strategies to break the chain link between plaque vulnerability and adverse clinical events include optimized pharmacologic prevention and potentially also preemptive percutaneous coronary interventions (previously defined as "plaque sealing" or "plaque passivation"). Various morphologic features of the vulnerable plaques have been described, including aspects regarding the large necrotic lipid content, the thin fibrous cap, the presence and extent of the presence of calcifications with small size and calcification angle, and as well as the large macrophage infiltration within the plaque. The detection of these features of plaque vulnerability is possible with intravascular imaging modalities such as intravascular ultrasound (IVUS), near-infrared spectroscopy (NIRS), and optical coherence tomography (OCT). This review explores the peculiarities of these three imaging modalities for the detection of vulnerable coronary plaque features.

SCAI Expert Consensus Statement on the Management of Patients With STEMI Referred for Primary PCI

ST-elevation myocardial infarction (STEMI) remains a leading cause of morbidity and mortality in the United States. Timely reperfusion with primary percutaneous coronary intervention is associated with improved outcomes. The Society for Cardiovascular Angiography & Interventions puts forth this expert consensus document regarding best practices for cardiac catheterization laboratory team readiness, arterial access with an algorithm to help determine proper arterial access in STEMI, and diagnostic angiography. This consensus statement highlights the strengths and limitations of various diagnostic and therapeutic interventions to access and treat a patient with STEMI in the catheterization laboratory, reviews different options to manage large thrombus burden during STEMI, and reviews the management of STEMI across the spectrum of various anatomical and clinical circumstances.

In-stent restenosis caused by a reprotruding calcified nodule and stent fracture in the hinged coronary artery

Calcified nodules (CNs) cause in-stent restenosis (ISR) frequently. Although reprotrusion of CNs through stent struts is one of the mechanisms of ISR, the process of this phenomenon has not been understood. Furthermore, little is known about stent fracture (SF) occurring at the site of CNs. We are presenting a case of an 82-year-old male who developed early ISR due to the combination of an in-stent CN and SF in the hinged right coronary artery. The process of progression of the in-stent CN was recorded sequentially with angiography and intravascular ultrasound (IVUS). IVUS from the fulcrum of hinge motion revealed the repetitive protruding movement of the CN into the stent lumen.

Challenges and Advances in Interventional Cardiology for Coronary Artery Disease Management

The development of percutaneous coronary intervention (PCI) has been one of the greatest advances in cardiology and has changed clinical practice for patients with coronary artery disease (CAD). Despite continuous improvements in operators' experience, techniques, and the development of new-generation devices, significant challenges remain in improving the efficacy of PCI, including calcification, bifurcation, multivascular disease, stent restenosis, and stent thrombosis, among others. The present review aims to provide an overview of the current status of knowledge of endovascular revascularization in CAD, including relevant trials, therapeutic strategies, and new technologies addressing particular scenarios that can impact the prognosis of this vulnerable population.