From the Guidelines
In the cath lab, managing intracoronary calcium requires a systematic approach, prioritizing rotational atherectomy as the primary adjunct device for severely calcified lesions, as it increases the chances of angiographic success. When dealing with severely calcified lesions, the evidence from nonrandomized single-arm studies, as outlined in the 2011 ACCF/AHA/SCAI guideline for percutaneous coronary intervention 1, suggests that rotational atherectomy is a valuable tool. This approach is crucial because severely calcified lesions respond poorly to balloon angioplasty and often result in incomplete and asymmetrical stent expansion when stents are implanted.
Key considerations in the approach to managing intracoronary calcium include:
- Identifying the extent of calcification through angiography or intravascular imaging (IVUS or OCT) to guide the treatment strategy.
- Employing a stepwise strategy based on the severity of calcification, with balloon-based techniques often sufficient for moderate calcification.
- Using dedicated calcium modification devices, such as rotational atherectomy, for severe calcification, with careful selection of burr sizes and operation speeds to minimize complications.
- Ensuring adequate lesion preparation before stent deployment to prevent stent underexpansion, malapposition, and subsequent restenosis or thrombosis, as highlighted by the challenges in managing severely calcified lesions 1.
The use of rotational atherectomy before implantation of bare-metal stents (BMS) or drug-eluting stents (DES) has been shown to be safe in retrospective studies, with intermediate-term patency favoring DES over BMS 1. Therefore, the recommendation for managing intracoronary calcium in the cath lab emphasizes the importance of rotational atherectomy in facilitating successful PCI in severely calcified lesions, while also considering the type of stent to be implanted for optimal outcomes.
From the Research
Approach to Managing Intracoronary Calcium in the Cath Lab
In the cath lab, managing intracoronary calcium is crucial for successful percutaneous coronary intervention (PCI). The following approaches are used:
- Atherectomy Techniques: Rotational atherectomy (RA), orbital atherectomy (OA), and excimer laser coronary angioplasty (ELCA) are used to modify calcified lesions and improve PCI outcomes 2.
- Device Selection: The selection of appropriate devices and adequate training are crucial for optimizing lesion modification and enhancing procedural success 2.
- Lesion Preparation: Lesion preparation with RA, plain old balloon angioplasty (POBA), or cutting-balloon angioplasty (CBA) may be associated with similar clinical outcomes in patients undergoing percutaneous intervention with drug-eluting stents (DES) 3.
Comparison of Atherectomy Techniques
Studies have compared the safety and efficacy of different atherectomy techniques:
- Rotational vs. Orbital Atherectomy: Both RA and OA are safe and effective strategies for the treatment of calcified coronary plaque prior to stent deployment, with similarly low rates of peri-procedural adverse events 4.
- Rotational Atherectomy and Cutting Balloon: The combination of RA and cutting balloon (RACB) had a similar risk of major adverse cardiac events (MACE), all-cause mortality, device success, and complication, but a lower risk of target lesion revascularization compared to RA and plain balloon (RAPB) 5.
- Combined Rotational Atherectomy and Cutting Balloon: The Rota-Cut combination resulted in higher in-stent acute lumen gain and larger minimal stent area compared with historical control of RA or modified balloon alone, but was not associated with higher stent expansion 6.
Key Considerations
When managing intracoronary calcium in the cath lab, the following key considerations should be taken into account:
- Patient Selection: Patient selection and lesion characteristics are crucial in determining the best approach for managing intracoronary calcium.
- Device Selection: The selection of appropriate devices and techniques is critical for optimizing lesion modification and enhancing procedural success.
- Procedural Techniques: Procedural techniques, such as lesion preparation and stent implantation, should be carefully planned and executed to minimize complications and optimize outcomes.