SASCI-Mayo Clinic fellows webinar: Calcium modification in percutaneous coronary intervention

Abstract

Introduction: This publication is a continuation of a series of webinars hosted by the South African Society of Cardiovascular Intervention (SASCI) in conjunction with the Mayo Clinic. This webinar provided a comprehensive overview of coronary calcification and strategies to manage calcified lesions during percutaneous coronary intervention (PCI), together with 2 case presentations.

Objective: To review c oronary calcification and calcium modification in contemporary PCI. We address the clinical significance of calcification, pathophysiology, the role of coronary imaging, and highlight various scenarios where different tools can be used to modify coronary calcium during PCI, thus optimising procedural outcomes.

Case 1 summary: A 53-year-old female with hypertension and poorly controlled type 2 diabetes presented with a high-risk non-ST-segment elevation myocardial infarction (NSTEMI). The left main and left anterior descending artery (LAD) were severely calcified, and the LAD was deemed a poor target for surgical revascularisation. The discussion involved decision-making regarding revascularisation strategies in high-risk NSTEMIs, comparing the utility of intravascular ultrasound (IVUS) versus optical coherence tomography (OCT) in coronary calcification, highlighting the various tools that can be used for calcium modification, and comparing rotational versus orbital atherectomy. Following dilation using a non-compliant balloon to allow successful delivery of the selected device, orbital atherectomy was used to modify the calcium, followed by a successful drug-eluting stent placement.

Case 2 summary: A 74-year-old male with hypertension, diabetes, and obstructive sleep apnoea presented with chest pain complicated by monomorphic ventricular tachycardia (VT). Clinically indicated coronary angiography documented severe nodular calcification. Treatment strategies and the challenges encountered with nodular calcification were discussed, with an emphasis on the importance of appropriately selecting the right calcium modification strategy and a focus on intravascular lithotripsy (IVL). The patient underwent successful revascularisation to the LAD and circumflex following calcium modification to the LAD. IVUS performed after stenting showed an excellent treatment result in this highly complex lesion and case.

Key messages:

• Understanding the types of coronary calcification and the importance of addressing calcium during PCI.
• Identifying and classifying the severity of coronary calcification using intravascular imaging (IVUS or OCT).
• Understanding the various modalities available for calcium modification and appropriately selecting the right modality in different clinical situations.
• Anticipating the potential complications that may arise during calcium modification and how to mitigate them.

Keywords: coronary artery calcification, intracoronary imaging, intravascular lithotripsy, orbital atherectomy, percutaneous coronary intervention, rotational atherectomy.