How Do We Treat Complex Calcified Coronary Artery Disease?

OPINION STATEMENT: Despite significant advances in treatment of coronary artery disease and improvements in interventional devices and techniques, the subset of obstructive calcified coronary artery disease remains challenging to treat. Percutaneous treatment of these lesions results in increased rates of procedural complications, as well as a higher risk of stent underexpansion and malapposition. This is associated with higher rates of restenosis, target lesion revascularization (TLR), and major adverse cardiac events (MACE). Several interventional strategies and technologies have been developed to improve lesion preparation and successful stent implantation. This includes use of cutting and scoring balloons and atherectomy devices. Several intravascular imaging techniques have also shown to have value in the treatment of complex calcified coronary lesions. These advances have improved the treatment of patients with calcified coronary disease who are often difficult to treat and frequently excluded from large randomized trials. Thoughtful, and not routine, use of rotational atherectomy can be helpful in pre-treating severely calcified lesions to achieve successful stent delivery. Orbital atherectomy represents a newer advancement in the atherectomy approach that may be beneficial in the treatment of calcified coronary disease, but further trials are needed to support its routine use.