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CALCIUM MODIFICATION TECHNIQUES IN COMPLEX PCI

The document discusses calcium modification techniques in percutaneous coronary intervention (PCI) by Dr. Thiều Minh Sơn, focusing on the prevalence of coronary artery calcification (CAC), its assessment, and various techniques to manage severely calcified lesions. It highlights the impact of CAC on procedural success rates and complications and explores imaging modalities for CAC assessment. The document concludes that strategies such as high-pressure balloons and cutting balloons can effectively enhance stent expansion in the presence of significant calcification.

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CALCIUM MODIFICATION TECHNIQUES IN COMPLEX PCI Dr. Thiều Minh Sơn, MD Interventional Cardiology Fellow at Khánh Hòa Provincial General Hospital Nha Trang, July 20th 2023
CONTENTS 1. Introduction 2. Calcification assessment 3. Calcium modification techniques 4. Conclusions
01. INTRODUCTION
CORONARY ARTERY CALCIFICATION J Geriatr Cardiol 2015; 12: 668 675. doi:10.11909/j.issn.1671-5411.2015.06.012 A B • Highly prevalent in patients with coronary heart disease (CHD) • Prevalence of CAC is age- and gender-dependent, occurring in over 90% of men and 67% of women older than 70 years of age • Other risk factors: hypertension, diabetes mellitus, dyslipidemia, chronic kidney disease, obesity, familial history of CAC, high fibrinogen level, high CRP level • 2 types of CAC: intimal and medial • Associated with major adverse cardiovascular events • Usually be found in patients with severe CHD, but can be asymptomatic → early diagnosis is important
PREVALENCE American Journal of Preventive Cardiology 12 (2022) 100392. DOI:https://doi.org/10.1016/j.ajpc.2022.100392 A B
PATHOGENIC MECHANISM Cleveland Clinic Journal of Medicine September 2018, 85 (9) 707-716; DOI: https://doi.org/10.3949/ccjm.85a.17097 A B • Type 1: contains lipoproteins → initiate an inflammatory response • Type 2: accumulation of foam cells • Type 3: contains extracellular lipid droplets • Type 4: extracellular lipid pools form a lipid core • Type 5: lipid core develops a fibrous connective-tissue thickening that can calcify → detectable by imaging • Type 6: complicated lesion that can include thrombus from plaque rupture CAC score: coronary artery calcium score
CLASSIFICATION Cleveland Clinic Journal of Medicine September 2018, 85 (9) 707-716; DOI: https://doi.org/10.3949/ccjm.85a.17097 A B Calcium lesions: • Superficial (intimal): present at the intimal– lumen interface or closer to the lumen than to the adventitia • Deep (medial): located at the media/adventitia border or closer to the adventitia than to the lumen.
CALCIUM DISTRIBUTION Front. Cardiovasc. Med., 06 April 2023. Sec. Cardiovascular Imaging. Volume 10 – 2023. DOI: https://doi.org/10.3389/fcvm.2023.1133510 A B
CORONARY ARTERY CALCIFICATION Catheter Cardiovasc Interv. 2020;doi:10.1002/ccd.28994 A B • Coronary lesions with severe calcification are classified as complex lesions • Known to carry lower success rates and higher complication rates following PCI • Poses technical challenges during PCI → in stent under-expansion, malapposition, or the inability to place a stent • May damage the polymer coating of DES → DES ineffectiveness when implanted
Catheter Cardiovasc Interv. 2018 Apr 1;91(5):859-866. doi: 10.1002/ccd.27204. Epub 2017 Jul 19. A B
PREVALENCE J Am Heart Assoc. 2021;10:e022513. https://doi.org/10.1161/JAHA.121.022513 A B
02. CALCIFICATION ASSESSMENT
IMAGING MODALITIES Circulation. 2022;145:e18–e114. DOI: 10.1161/CIR.0000000000001038 A B Imaging modalities for identifying and characterizing calcified coronary lesions: • Coronary angiography • Coronary CT angiography • Intravascular imaging: • Intravascular ultrasound (IVUS) • Optical coherence tomography (OCT)
CORONARY ANGIOGRAPHY European Heart Journal Supplements (2023) 25 (Supplement C), C68–C73 A B • Calcified lesions will appear as an area of attenuation of the X-rays: • Visible already before the contrast injection • Arranged along the contour of the vessel • Moves with heart movement. • Angiography alone has been shown to have low sensitivity in identifying calcified lesions → necessary to combine with intravascular imaging
CORONARY ANGIOGRAPHY Kini, A., Sharma, S. K. (Eds.). (2021). Practical manual of interventional cardiology. Springer London. DOI: https://doi.org/10.1007/978-3-030-68538-6 A B Example 1: Left and right panels are coronary angiographic images before and after the injection of a radio-contrast agent, respectively. Arrows indicate presence of faint radio-opaque lesions after the injection of a radio-contrast → mild calcification.
Tohoku J. Exp. Med., 2015, 235, 135-144 A B Example 2: Both left and right panels are images before the injection of a radio-contrast agent. There is no radio-opaque lesion during diastolic movement (left panel). Arrows indicate the presence of radio-opaque lesions during systolic movement (right panel) → moderate calcification Example 3: Arrows indicate the presence of radio- opaque lesions before the injection of a radio-contrast agent irrespective of heart movement (diastolic movement on left panel and systolic movement on right panel) → severe calcification
Coronary CT Angiography (CCTA) Clinical Imaging 77 (2021) 1–8. DOI: https://doi.org/10.1016/j.clinimag.2021.02.016 A B A: No CAC within the partially imaged LAD B: CAC involves <1/3 LAD length C: CAC involves 1/3 – 2/3 LAD length D: CAC involves >2/3 LAD length and branch vessels E: Stent within the LAD precludes CAC assessment.
CCTA INDICATIONS Journal of Cardiovascular Computed Tomography 15 (2021) 290–303 A B
CCTA INDICATIONS Journal of Cardiovascular Computed Tomography 15 (2021) 290–303 A B
Journal of Cardiovascular Computed Tomography 15 (2021) 290–303 A B CCTA features associated with an increased risk of MACE: a. Extensive non-obstructive calcified plaque in the left main, proximal-mid LAD, proximal LCX, and OM1 b. An atherosclerotic plaque with positive remodeling, low-attenuation plaque, and napkin-ring sign in the proximal LAD c. ICA demonstrating occlusion of the proximal LAD at the site of high-risk plaque 10 months after coronary CTA (arrows).
CCTA INDICATIONS Diagnostics 2023, 13(12), 2074; https://doi.org/10.3390/diagnostics13122074 A B
CAC SCORE Journal of Cardiovascular Computed Tomography 15 (2021) 290–303 A B
PREVALENCE J Am Coll Cardiol Img 2017;10:923–37. DOI: https://doi.org/10.1016/j.jcmg.2017.05.007 A B
PREVALENCE J Am Coll Cardiol Img 2017;10:923–37. DOI: https://doi.org/10.1016/j.jcmg.2017.05.007 A B
PREVALENCE JACC: Cardiovascular Imaging, Volume 14, Issue 12,2021,Pages 2443-2452 ISSN 1936-878X, https://doi.org/10.1016/j.jcmg.2021.01.024. A B
CCTA INDICATIONS Curr Cardiovasc Imaging Rep (2015) 8:18. DOI 10.1007/s12410-015-9334-0 A B
Timeline of advances in interventional cardiology Current Cardiovascular Risk Reports 16(6). DOI:10.1007/s12170-021-00686-4 A B
IVUS/OCT Circ Cardiovasc Interv. 2021;14:e009870. DOI: 10.1161/CIRCINTERVENTIONS.120.009870 A B • The use of intracoronary imaging to guide PCI improves procedural and long-term clinical outcomes • Provide important insights into coronary lesion morphology → detecting, localizing, and quantifying coronary calcification • Assist with assessing the need for lesion preparation, stent sizing, minimizing geographic miss, verifying stent expansion, evaluating complications, and identifying causes of stent failure
OCT/IVUS J Am Coll Cardiol Img. 2017 Dec, 10 (12) 1487–1503 A B • OCT and IVUS images from the same lesions • Red dotted line: EEL (external elastic lamina) • Yellow dotted line: internal elastic lamina • Blue dotted line: lumen surface • Yellow double arrowhead: (EEL) diameter • White double arrow head: Lumen diameter
OCT/IVUS J Am Coll Cardiol Img. 2017 Dec, 10 (12) 1487–1503 A B • (A’) and (A’’) are OCT and IVUS images corresponding to the arrow in (A) in a patient with stable angina who suffered peri-procedural myocardial infarction after stenting • A’: a large lipid rich plaque defined by diffuse border with attenuation by OCT • A’’: a large attenuated plaque defined as echo attenuation without hyperechoic leading edge by IVUS • B (OCT) and B’ (IVUS) show calcified plaque. The thickness of calcium can be measured only by OCT (1.05 mm), and the calcium angle measured 130 degree by both IVUS and OCT.
J Am Coll Cardiol Intv 2019;12:1465–78 A B IMAGING MODALITIES
Circulation. 2022;145:e18–e114. DOI: 10.1161/CIR.0000000000001038 A B 2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines
J. Pers. Med. 2022, 12, 1638. DOI: https://doi.org/10.3390/jpm12101638 B Severity Classification
J. Pers. Med. 2022, 12, 1638. DOI: https://doi.org/10.3390/jpm12101638 B Severity Classification
03. CALCIUM MODIFICATION TECHNIQUES
TECHNIQUES Circ Cardiovasc Interv. 2021;14:e009870. DOI: 10.1161/CIRCINTERVENTIONS.120.009870 A B Balloon-Based Devices: • Non-Compliant Balloons • High-Pressure (Dual-Layer) Non-Compliant Balloons • Cutting Balloons • Scoring Balloons • Intravascular Lithotripsy Coronary Atherectomy: • Rotational Atherectomy • Orbital Atherectomy • Laser Atherectomy
BALLOON COMPLIANCE Hoballah, J.J., Bechara, C.F. (2021) Vascular Reconstructions. Springer, New York, NY. https://doi.org/10.1007/978-1-0716-1089-3_22 B • Balloon compliance: the change in balloon diameter per atmosphere of inflation pressure (“stretchability” of a balloon) → approximately 0.095 mm/atm for semi-compliant balloons, and 0.01 mm/atm for non- compliant balloons • Semi-compliant balloons: • Expand in diameter as the atmospheres increased • May result in a “dog bone” shape as it expands in a lesion • Non-compliant balloons: • Maintain a consistent diameter throughout their length as they inflate, even at high pressures
NON-COMPLIANT BALLOONS (NCB) Circ Cardiovasc Interv. 2021;14:e009870. DOI: 10.1161/CIRCINTERVENTIONS.120.009870 B • Single layer • Can be expanded to high pressures (20–24 atm) • Failure: • Eccentric calcium → guidewire bias may direct force toward the non-calcified segments of the artery • Concentric calcium → insufficient force fails to induce calcium fracture • Possible complications: balloon rupture, vessel dissection, or perforation
Cuculi F, et al. Open Heart 2020;7:e001204. doi:10.1136/openhrt-2019-001204 B
Cuculi F, et al. Open Heart 2020;7:e001204. doi:10.1136/openhrt-2019-001204 B
Cuculi F, et al. Open Heart 2020;7:e001204. doi:10.1136/openhrt-2019-001204 B CONCLUSIONS: In simple coronary lesions, predilatation/ postdilatation with NCBs at high pressures appears to be safe and result in better scaffold and stent expansion. Using SCBs only for predilatation might lead to inadequate stent expansion and postdilatation with NCBs might only partially correct this.
HIGH-PRESSURE NC BALLOONS Circ Cardiovasc Interv. 2021;14:e009870. DOI: 10.1161/CIRCINTERVENTIONS.120.009870 B • Dual layer • Low profile • Can exert super high pressures on the lesion (35atm rated pressure) • Data for this device are limited to small case series, but all portray a device that is simple to use and effective, with no signal of increased risk • When conventional NCB’s fail → high-pressure NC balloons provide an effective strategy • It remains unclear when this device would be of definitive benefit → lesion selection remains challenging • Potential risk: coronary dissection, perforation, localized wall injury (may provide a substrate for restenosis)
Catheter Cardiovasc Interv. 2010 Jun 1;75(7):1067-73. doi: 10.1002/ccd.22430. B
Am J Cardiol . 1995 Sep 1;76(7):518-20. doi: 10.1016/s0002-9149(99)80143-x. B
Cardiovasc Revasc Med. 2019 Dec;20(12):1083-1087. doi: 10.1016/j.carrev.2019.02.026. Epub 2019 Mar 1. B
Cardiovasc Revasc Med. 2019 Dec;20(12):1083-1087. doi: 10.1016/j.carrev.2019.02.026. Epub 2019 Mar 1. B RESULTS: Angiographic success was achieved in 97.5%, procedural success in 96.6%. The OPN alone was able to achieve adequate expansion in >90%. 0.9% days MACE were reported. CONCLUSION: The OPN-dedicated high-pressure balloon provides an effective and safe strategy for treatment of severe resistant coronary lesions.
CUTTING BALLOON Hoballah, J.J., Bechara, C.F. (2021) Vascular Reconstructions. Springer, New York, NY. https://doi.org/10.1007/978-1-0716-1089-3_22 B • First developed in the mid-1980s by Dr. Peter Barath → initially called the Barath Balloon • Composed of a conventional balloon with three or four atherotomes (microsurgical blades) that are mounted longitudinally along the balloon surface • Provides a focused force at low pressure → create controlled incisions along the lesion length → greater vessel compliance + improved stent expansion • Cons: bulky device → difficulty in delivering
CUTTING BALLOON Hoballah, J.J., Bechara, C.F. (2021) Vascular Reconstructions. Springer, New York, NY. https://doi.org/10.1007/978-1-0716-1089-3_22 B • The diameter of the cutting balloon is selected to approximate a 1.0 : 1.1 ratio (balloon to the reference vessel diameter) → oversizing increases the risk of perforation and rupture • Balloon lengths are often shorter than conventional balloons, usually 15–20 mm • Should be inflated and deflated slowly (generally 1 atm every 2–3 seconds) to avoid damaging their structural integrity • Some authors advocate rotating the balloon and inflating it multiple times to score the lesion
CUTTING BALLOON Am J Cardiol . 1995 Sep 1;76(7):518-20. doi: 10.1016/s0002-9149(99)80143-x. B Figure 6. Optical coherence tomography (OCT) images of cutting balloon use. A, Pre-percutaneous coronary intervention OCT image deep (0.90 mm) calcific nodule (lower left quadrant) encroaching on vessel lumen. Minimal luminal area in this segment is 3.51 mm2. B, OCT image immediately following 1:1 sized cutting balloon, showing improved minimal luminal area (7.52 mm2) and signs of vessel preparation with balloon-associated dissection evident (at 7 and 9 o’clock).
J. Pers. Med. 2022, 12, 1638. DOI: https://doi.org/10.3390/jpm12101638 B
J Geriatr Cardiol 2014; 11: 44−49. doi: 10.3969/j.issn.1671-5411.2014.01.012 B
J Geriatr Cardiol 2014; 11: 44−49. doi: 10.3969/j.issn.1671-5411.2014.01.012 B CONCLUSIONS: Cutting balloon angioplasty before DES implantation in severely calcified lesions appears to be more efficacies including significantly larger final stent CSA and larger acute lumen gain, without increasing complications during operations and the MACE rate in 6-month.
J Invasive Cardiol. 2015 Sep;27(9):387-91. B
J Invasive Cardiol. 2015 Sep;27(9):387-91. B CONCLUSIONS: A strategy of lesion preparation with RA, POBA, or CBA in HCCL may be associated with similar clinical outcomes in patients undergoing percutaneous intervention with DES. The RA group had a trend toward greater MACE, death, and TLR.
SCORING BALLOON Circ Cardiovasc Interv. 2021;14:e009870. DOI: 10.1161/CIRCINTERVENTIONS.120.009870 B • Consist of a semi-compliant balloon with 3-4 rectangular nitinol-based struts that encircle the balloon in a helical pattern • Mechanistic evolution of the CB: • Reducing the mechanical trauma exerted on the vessel wall → lower risk of dissection • More deliverable
Cardiovasc Interv Ther. 2019 Jul;34(3):242-248. doi: 10.1007/s12928-018-0553-6. Epub 2018 Oct 19. B
SCORING BALLOON Cardiovasc Interv Ther. 2019 Jul;34(3):242-248. doi: 10.1007/s12928-018-0553-6. Epub 2018 Oct 19. B A: Cross-sectional coronary calcification. B: The image shows the thicknesses of the calcifications (520, 470, and 440 µm), and 3 disruption sites can be seen (after modification by scoring balloon). In this case, the coronary calcification angle was 360° and the shape was non-convex
J. Pers. Med. 2022, 12, 1638. DOI: https://doi.org/10.3390/jpm12101638 B
SCORING BALLOON Int J Cardiol. 2016 Oct 15;221:23-31. doi: 10.1016/j.ijcard.2016.07.002. Epub 2016 Jul 4. B
SCORING BALLOON Int J Cardiol. 2016 Oct 15;221:23-31. doi: 10.1016/j.ijcard.2016.07.002. Epub 2016 Jul 4. B
SCORING BALLOON Int J Cardiol. 2016 Oct 15;221:23-31. doi: 10.1016/j.ijcard.2016.07.002. Epub 2016 Jul 4. B
OUTCOMES Int J Cardiol. 2016 Oct 15;221:23-31. doi: 10.1016/j.ijcard.2016.07.002. Epub 2016 Jul 4. B RESULTS: Stent expansion was significantly higher after predilation by a scoring balloon (68.0% vs. 62.1%, p = 0.017) with similar stent lumen eccentricity (0.84 vs. 0.80, p = 0.18). Intimal disruption was induced significantly more frequently (68.0% vs. 38.4%, p = 0.035) and was more extensive in the scoring group (122° vs. 65°, p = 0.038). Adverse clinical events including death, myocardial infarction, and stent thrombosis were not observed up to 9 months after PCI in both groups. CONCLUSIONS: In this randomized study, pretreatment with a scoring balloon enhanced stent expansion partly through induction of intimal disruption
INTRAVASCULAR LITHOTRIPSY (IVL) J Am Coll Cardiol Intv 2021;14:1275–92 B • Terminology: Lithotripsy = breaking stones (Greek) • A non-invasive procedure involving the physical destruction of hardened masses like kidney stones or gallstones • Techniques: • Extracorporeal shockwave lithotripsy (ESWL) • Intracorporeal shockwave lithotripsy (ISWL) • Intravascular lithotripsy (IVL)
B J Am Coll Cardiol Intv 2021;14:1275–92 MECHANISM
B J Am Coll Cardiol Intv 2021;14:1275–92 MECHANISM
MECHANISM Interventional Cardiology Review 2019;14(3):174–81. DOI: https://doi.org/10.15420/icr.2019.18.R1 B • Energy discharged from the spark gap between 2 electrodes → formation of a plasma vapor bubble in the saline/contrast mixture within the balloon → rapidly expanding and collapsing → generates high-amplitude ultrasonic pressure shockwaves → expands spherically outwards from the emitters • Shockwaves creates fracturing effects when encounters tissue with differing acoustic impedances, but travel through (with minimal effect) when encounters tissue with similar acoustic impedance • Acoustic impedance: • Water: 1.500.000 kg/m2/s • Kidney: 1.600.000 kg/m2/s • Muscle: 1.700.000 kg/m2/s • Calcified tissue: 7.800.000 kg/m2/s
J Am Coll Cardiol Intv 2021;14:1275–92 B (A) The intravascular lithotripsy (IVL) balloon catheter is positioned across the target lesion (sized with a ratio of 1:1 with the target vessel, advanced over a standard work-horse guidewire) and inflated to 4 atm (B) Emitter spark gap discharge produces compressive shockwaves that emanate spherically outward; vapor bubble formation is contained with the integrated balloon. (C) IVL shockwaves affect superficial and deep calcium (D) After IVL therapy is delivered, the balloon is inflated to 6 atm prior to deflation. IVL SHOCKWAVE GENERATION
J Am Coll Cardiol Img 2017;10:897–906 B OCT Characterization of Calcified Lesions and the Effects of Lithoplasty and Stenting (A) OCT cross sections acquired before lithoplasty in 3 different segments of a calcified lesion (B) Post-lithoplasty, there were multiple fractures noted in the same frames (arrows), with an overall increase in the luminal area (C) After implantation of drug-eluting stents, the fractures were noted to become deeper (arrows), with further increase in acute area gain, resulting in favorable stent expansion and apposition.
JACC: Asia. 2023 Apr, 3 (2) 185–197 B (A) Pre-PCI CAG shows significant calcified plaques in RCA (B) Inflated NC balloon shows dog boning indicating unyielding calcified lesion (C) Post-PCI CAG shows fully expanded stent deployed after IVL modification (D) Pre-IVL IVUS imaging shows a superficial 360 degree arch of superficial calcium (E) IVUS post-IVL shows calcified plaque after IVL, which shows fractures.
JACC: Asia. 2023 Apr, 3 (2) 185–197 B (A) Pre-PCI CAG showing diffuse ISR (in-stent restenosis) in RCA (B) Pre-IVL IVUS showing the under-deployed stent and calcified ISR (C) Inflated NC shows under-expansion, indicating an unyielding calcified lesion (D) Post-IVL IVUS shows some expansion of the stent in the lesion (E) The fully expanded stent after IVL (F) Post-PCI CAG showing the fully expanded stents
J. Pers. Med. 2022, 12, 1638. DOI: https://doi.org/10.3390/jpm12101638 B
J Am Coll Cardiol Intv. 2021 Jun, 14 (12) 1337–1348 B
J Am Coll Cardiol Intv. 2021 Jun, 14 (12) 1337–1348 B
J Am Coll Cardiol Intv. 2021 Jun, 14 (12) 1337–1348 B CONCLUSIONS: In the largest cohort of patients treated with coronary IVL assessed to date, coronary IVL safely facilitated successful stent implantation in severely calcified coronary lesions with a high rate of procedural success.
CORONARY ATHERECTOMY Interventional Cardiology Review 2019;14(3):182–9. DOI:https://doi.org/10.15420/icr.2019.17.R1 B Rotational atherectomy Orbital atherectomy Laser atherectomy
ROTATIONAL ATHERECTOMY Circ Cardiovasc Interv. 2021;14:e009870. DOI: 10.1161/CIRCINTERVENTIONS.120.009870 B • RA uses a diamond encrusted elliptical burr passed into the coronary artery over a specialized 0.009 inch guidewire (Rotawire) • The burr rotates at speeds of 140.000 to 220.000 rpm (monodirectional) and abrades non-elastic, fibro-calcified tissue into small particles (<10 μm) while deflecting off softer elastic tissue • The debris from the lesion passes downstream and cleared by the reticuloendothelial system.
Interventional Cardiology Review 2019;14(3):182–9. DOI:https://doi.org/10.15420/icr.2019.17.R1 B
ROTATIONAL ATHERECTOMY Circ Cardiovasc Interv. 2021;14:e009870. DOI: 10.1161/CIRCINTERVENTIONS.120.009870 B • Historically had increased peri- procedural and post-procedural complications, with complication rates as high as 9.7% • Most complications are common to all PCI procedures • Some risks are unique to RA: • Burr entrapment • RotaWire fracture • No flow/slow flow • Atrio-ventricular block requiring trans-venous pacing
Interventional Cardiology Review 2019;14(3):182–9. DOI:https://doi.org/10.15420/icr.2019.17.R1 B COMPLICATIONS
Interventional Cardiology Review 2019;14(3):182–9. DOI:https://doi.org/10.15420/icr.2019.17.R1 B
J. Pers. Med. 2022, 12, 1638. DOI: https://doi.org/10.3390/jpm12101638 B
Circulation: Cardiovascular Interventions. 2018;11:e007415. DOI: https://doi.org/10.1161/CIRCINTERVENTIONS.118.007415 B
Circulation: Cardiovascular Interventions. 2018;11:e007415. DOI: https://doi.org/10.1161/CIRCINTERVENTIONS.118.007415 B
Circulation: Cardiovascular Interventions. 2018;11:e007415. DOI: https://doi.org/10.1161/CIRCINTERVENTIONS.118.007415 B CONCLUSION: In patients with severely calcified coronary lesions: • Elective RA is feasible in nearly all patients and the acute success rate is superior to modified balloons. • Both approaches (elective RA and balloon plus bailout RA) are equally safe and effective. • Use of RA is no longer associated with excessive LLL (late-lumen-loss) in the era of modern SES.
ORBITAL ATHERECTOMY Circ Cardiovasc Interv. 2021;14:e009870. DOI: 10.1161/CIRCINTERVENTIONS.120.009870 B • A relatively recent advancement in the field of atheroablation • FDA approval in 2013 • Used a burr with a diamond-coated crown that orbits in an elliptical path within the artery • Pass over a specialist 0.014′′ wire (ViperWire) • The crown’s ablates the calcified lumen→ produces smaller particles of debris<2 μm • Unlike RA, there is continuous blood flow through the artery during ablation → potentially reduce the risk of slow-flow/no reflow, decrease thermal injury and obviate the need for the routine use of temporary pacing
J. Pers. Med. 2022, 12, 1638. DOI: https://doi.org/10.3390/jpm12101638 B Eccentrically mounted diamond-coated crown uses centrifugal force to orbit → bidirectional burr (a) one rotational cycle (b) one orbital cycle observed by high-speed camera in axial direction when the crown rotates at 90,000 rpm (c) front and (d) perspective schematic views of the crown rotation and orbiting.
J. Pers. Med. 2022, 12, 1638. DOI: https://doi.org/10.3390/jpm12101638 B MECHANISM OF ACTION DIFFERENTIAL ORBITAL SANDING Crown will only sand the hard components of the plaque Soft components (plaque/tissue) flex away from the crown ORBITAL MECHANISM: Increased speed → Increased centrifugal force Greater centrifugal force → Larger orbital diameter
ORBITAL ATHERECTOMY Circ Cardiovasc Interv. 2021;14:e009870. DOI: 10.1161/CIRCINTERVENTIONS.120.009870 B • The crown’s orbital diameter expands radially with increasing centrifugal force → allows the operator to control the depth of the ablation (by varying the speed of the burr) → avoids the need to change the burr multiple times + increasing procedural efficiency • Owing to the elliptical mechanism of action, OA is contraindicated in vessel diameters <2.5mm due to increased risk of vessel perforation Eccentric head wobbles Cutting head diamonds
J. Pers. Med. 2022, 12, 1638. DOI: https://doi.org/10.3390/jpm12101638 B
JACC Cardiovasc Interv. 2014 May;7(5):510-8. doi: 10.1016/j.jcin.2014.01.158. B
JACC Cardiovasc Interv. 2014 May;7(5):510-8. doi: 10.1016/j.jcin.2014.01.158. B Primary Safety Endpoint
JACC Cardiovasc Interv. 2014 May;7(5):510-8. doi: 10.1016/j.jcin.2014.01.158. B Primary Efficacy Endpoint Conclusions: The ORBIT II coronary OAS trial met both the primary safety and efficacy endpoints by significant margins. Preparation of severely calcified plaque with the OAS not only helped facilitate stent delivery, but improved both acute and 30-day clinical outcomes compared with the outcomes of historic control subjects in this difficult-to-treat patient population.
LASER ATHERECTOMY Circulation: Cardiovascular Interventions. 2021;14. DOI: https://doi.org/10.1161/CIRCINTERVENTIONS.120.010061 B • Excimer laser coronary angioplasty (ELCA) uses a pulse waved, ultraviolet laser catheter to vaporize cadaveric atherosclerotic tissue with minimal thermal damage • Has been available for >25 years for the percutaneous treatment of coronary artery stenoses • Was shown to be effective in coronary lesions poorly treated with balloon angioplasty alone, including aorto-ostial lesions, long calcified lesions, and saphenous vein graft (SVG) lesions. • ELCA is one of the most useful techniques in calcified lesions that are truly uncrossable • Use of ELCA in PCIs has seen an increase, although overall use remains low
EQUIPMENTS Interventional Cardiology Review, 2016;11(1):27–32. DOI: 10.15420/icr.2016:2:2 B The Spectranetics CVX-300 Excimer Laser System: • Pulse generator (A) • Control panel (B) • ELCA catheters (C) • Foot pedal (D)
MECHANISM Interventional Cardiology Review, 2016;11(1):27–32. DOI: 10.15420/icr.2016:2:2 B • Excimer lasers are pulsed gas lasers that use a mixture of a rare gas and halogen as an active medium to generate pulses of short wavelength, high-energy ultraviolet (UV) light. • Tissue ablation is carried out by 3 distinct mechanisms: • Photochemical: UV laser light is absorbed by intra- vascular material and breaks carbon–carbon bonds • Photothermal: UV laser light elevates the temperature of intra-cellular water → cellular rupture and generates a vapour bubble at the catheter tip • Photomechanical: Expansion and implosion of the vapour bubbles disrupts the obstructive intra- vascular material
LASER CATHETERS Circ Cardiovasc Interv. 2021;14:e009870. DOI: 10.1161/CIRCINTERVENTIONS.120.009870 B • Catheters comes in sizes of 0.9, 1.4, 1.7, and 2.0mm • Laser catheter size selection is primarily based on: • Severity of the lesion • Reference vessel diameter • Consistency of the target material • The 0.9- and 1.4-mm catheter are most commonly used and can be used in vessels >2.0 mm in diameter through a 6F guiding catheter • The larger diameter laser catheters (1.7, 2.0 mm) are primarily used in straight sections of vessels with a diameter >3.0 mm and require 7F and 8F guiding catheters, respectively. • Passed along a standard 0.014′′ work-horse guidewire → not require dedicated guidewires (that are often more difficult to deliver distally)
MECHANISM Cardiovascular Revascularization Medicine, https://doi.org/10.1016/j.carrev.2020.10.016 B
PROS & CONS Circ Cardiovasc Interv. 2021;14:e009870. DOI: 10.1161/CIRCINTERVENTIONS.120.009870 B • Provides a solution to a variety of problems that may be encountered, including: • Massive intra-coronary thrombus • Uncrossable lesions • Stent under-expansion. • CONS: • Expensive equipment, particularly if only used sparingly for PCI cases • Complexity surrounding its use (for example, operators and staff have to wear additional eye-protection to prevent retinal exposure to UV light)
J. Pers. Med. 2022, 12, 1638. DOI: https://doi.org/10.3390/jpm12101638 B
Lancet. 1996 Jan 13;347(8994):79-84. doi: 10.1016/s0140-6736(96)90209-3. B
Lancet. 1996 Jan 13;347(8994):79-84. doi: 10.1016/s0140-6736(96)90209-3. B OUTCOMES CONCLUSION: ELCA followed by balloon angioplasty provides no benefit additional to balloon angioplasty alone with respect to the initial and long-term clinical and angiographic outcome in the treatment of obstructive coronary artery disease.
CORONARY ATHERECTOMY Interventional Cardiology Review 2019;14(3):182–9. DOI:https://doi.org/10.15420/icr.2019.17.R1 B
JACC: Asia. 2023 Apr, 3 (2) 185–197 B
Circ Cardiovasc Interv. 2021;14:e009870. DOI: 10.1161/CIRCINTERVENTIONS.120.009870 B
JACC: Asia. 2023 Apr, 3 (2) 185–197 B
JACC: Asia. 2023 Apr, 3 (2) 185–197 B
Circ Cardiovasc Interv. 2021;14:e009870. DOI: 10.1161/CIRCINTERVENTIONS.120.009870 - European Heart Journal Supplements (2023) 25 (Supplement C), C68–C73 B CALCIUM MODIFICATION TREATMENT ALGORITHM
Catheter Cardiovasc Interv. 2020;doi:10.1002/ccd.28994 B
CONCLUSIONS 1. Coronary artery calcification represents a major challenge associated with adverse outcomes after PCI 2. To avoid stent failure, optimal plaque preparation of calcified coronary lesions is required 3. Intracoronary imaging and determination of coronary calcification severity and characteristics are the keys to guiding further treatment decisions. 4. Available modification techniques includes: Balloon-Based Devices (Non-Compliant Balloons, High-Pressure Non-Compliant Balloons, Cutting Balloons, Scoring Balloons, Intravascular Lithotripsy) and Coronary Atherectomy (Rotational Atherectomy, Orbital Atherectomy, Laser Atherectomy) 5. The decision relating to which modification technique to use is based on numerous anatomic and technical factors, including the location of the lesion, the concentricity of the calcium pool, operator familiarity/expertise, and local device availability.

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CALCIUM MODIFICATION TECHNIQUES IN COMPLEX PCI

  • 1.
    CALCIUM MODIFICATION TECHNIQUES INCOMPLEX PCI Dr. Thiều Minh Sơn, MD Interventional Cardiology Fellow at Khánh Hòa Provincial General Hospital Nha Trang, July 20th 2023
  • 2.
    CONTENTS 1. Introduction 2. Calcificationassessment 3. Calcium modification techniques 4. Conclusions
  • 3.
  • 4.
    CORONARY ARTERY CALCIFICATION J GeriatrCardiol 2015; 12: 668 675. doi:10.11909/j.issn.1671-5411.2015.06.012 A B • Highly prevalent in patients with coronary heart disease (CHD) • Prevalence of CAC is age- and gender-dependent, occurring in over 90% of men and 67% of women older than 70 years of age • Other risk factors: hypertension, diabetes mellitus, dyslipidemia, chronic kidney disease, obesity, familial history of CAC, high fibrinogen level, high CRP level • 2 types of CAC: intimal and medial • Associated with major adverse cardiovascular events • Usually be found in patients with severe CHD, but can be asymptomatic → early diagnosis is important
  • 5.
    PREVALENCE American Journal ofPreventive Cardiology 12 (2022) 100392. DOI:https://doi.org/10.1016/j.ajpc.2022.100392 A B
  • 6.
    PATHOGENIC MECHANISM Cleveland ClinicJournal of Medicine September 2018, 85 (9) 707-716; DOI: https://doi.org/10.3949/ccjm.85a.17097 A B • Type 1: contains lipoproteins → initiate an inflammatory response • Type 2: accumulation of foam cells • Type 3: contains extracellular lipid droplets • Type 4: extracellular lipid pools form a lipid core • Type 5: lipid core develops a fibrous connective-tissue thickening that can calcify → detectable by imaging • Type 6: complicated lesion that can include thrombus from plaque rupture CAC score: coronary artery calcium score
  • 7.
    CLASSIFICATION Cleveland Clinic Journalof Medicine September 2018, 85 (9) 707-716; DOI: https://doi.org/10.3949/ccjm.85a.17097 A B Calcium lesions: • Superficial (intimal): present at the intimal– lumen interface or closer to the lumen than to the adventitia • Deep (medial): located at the media/adventitia border or closer to the adventitia than to the lumen.
  • 8.
    CALCIUM DISTRIBUTION Front. Cardiovasc.Med., 06 April 2023. Sec. Cardiovascular Imaging. Volume 10 – 2023. DOI: https://doi.org/10.3389/fcvm.2023.1133510 A B
  • 9.
    CORONARY ARTERY CALCIFICATION Catheter CardiovascInterv. 2020;doi:10.1002/ccd.28994 A B • Coronary lesions with severe calcification are classified as complex lesions • Known to carry lower success rates and higher complication rates following PCI • Poses technical challenges during PCI → in stent under-expansion, malapposition, or the inability to place a stent • May damage the polymer coating of DES → DES ineffectiveness when implanted
  • 10.
    Catheter Cardiovasc Interv.2018 Apr 1;91(5):859-866. doi: 10.1002/ccd.27204. Epub 2017 Jul 19. A B
  • 11.
    PREVALENCE J Am HeartAssoc. 2021;10:e022513. https://doi.org/10.1161/JAHA.121.022513 A B
  • 12.
  • 13.
    IMAGING MODALITIES Circulation. 2022;145:e18–e114. DOI:10.1161/CIR.0000000000001038 A B Imaging modalities for identifying and characterizing calcified coronary lesions: • Coronary angiography • Coronary CT angiography • Intravascular imaging: • Intravascular ultrasound (IVUS) • Optical coherence tomography (OCT)
  • 14.
    CORONARY ANGIOGRAPHY European Heart JournalSupplements (2023) 25 (Supplement C), C68–C73 A B • Calcified lesions will appear as an area of attenuation of the X-rays: • Visible already before the contrast injection • Arranged along the contour of the vessel • Moves with heart movement. • Angiography alone has been shown to have low sensitivity in identifying calcified lesions → necessary to combine with intravascular imaging
  • 15.
    CORONARY ANGIOGRAPHY Kini, A.,Sharma, S. K. (Eds.). (2021). Practical manual of interventional cardiology. Springer London. DOI: https://doi.org/10.1007/978-3-030-68538-6 A B Example 1: Left and right panels are coronary angiographic images before and after the injection of a radio-contrast agent, respectively. Arrows indicate presence of faint radio-opaque lesions after the injection of a radio-contrast → mild calcification.
  • 16.
    Tohoku J. Exp.Med., 2015, 235, 135-144 A B Example 2: Both left and right panels are images before the injection of a radio-contrast agent. There is no radio-opaque lesion during diastolic movement (left panel). Arrows indicate the presence of radio-opaque lesions during systolic movement (right panel) → moderate calcification Example 3: Arrows indicate the presence of radio- opaque lesions before the injection of a radio-contrast agent irrespective of heart movement (diastolic movement on left panel and systolic movement on right panel) → severe calcification
  • 17.
    Coronary CT Angiography(CCTA) Clinical Imaging 77 (2021) 1–8. DOI: https://doi.org/10.1016/j.clinimag.2021.02.016 A B A: No CAC within the partially imaged LAD B: CAC involves <1/3 LAD length C: CAC involves 1/3 – 2/3 LAD length D: CAC involves >2/3 LAD length and branch vessels E: Stent within the LAD precludes CAC assessment.
  • 18.
    CCTA INDICATIONS Journal ofCardiovascular Computed Tomography 15 (2021) 290–303 A B
  • 19.
    CCTA INDICATIONS Journal ofCardiovascular Computed Tomography 15 (2021) 290–303 A B
  • 20.
    Journal of CardiovascularComputed Tomography 15 (2021) 290–303 A B CCTA features associated with an increased risk of MACE: a. Extensive non-obstructive calcified plaque in the left main, proximal-mid LAD, proximal LCX, and OM1 b. An atherosclerotic plaque with positive remodeling, low-attenuation plaque, and napkin-ring sign in the proximal LAD c. ICA demonstrating occlusion of the proximal LAD at the site of high-risk plaque 10 months after coronary CTA (arrows).
  • 21.
    CCTA INDICATIONS Diagnostics 2023,13(12), 2074; https://doi.org/10.3390/diagnostics13122074 A B
  • 22.
    CAC SCORE Journal ofCardiovascular Computed Tomography 15 (2021) 290–303 A B
  • 23.
    PREVALENCE J Am CollCardiol Img 2017;10:923–37. DOI: https://doi.org/10.1016/j.jcmg.2017.05.007 A B
  • 24.
    PREVALENCE J Am CollCardiol Img 2017;10:923–37. DOI: https://doi.org/10.1016/j.jcmg.2017.05.007 A B
  • 25.
    PREVALENCE JACC: Cardiovascular Imaging,Volume 14, Issue 12,2021,Pages 2443-2452 ISSN 1936-878X, https://doi.org/10.1016/j.jcmg.2021.01.024. A B
  • 26.
    CCTA INDICATIONS Curr CardiovascImaging Rep (2015) 8:18. DOI 10.1007/s12410-015-9334-0 A B
  • 27.
    Timeline of advancesin interventional cardiology Current Cardiovascular Risk Reports 16(6). DOI:10.1007/s12170-021-00686-4 A B
  • 28.
    IVUS/OCT Circ Cardiovasc Interv.2021;14:e009870. DOI: 10.1161/CIRCINTERVENTIONS.120.009870 A B • The use of intracoronary imaging to guide PCI improves procedural and long-term clinical outcomes • Provide important insights into coronary lesion morphology → detecting, localizing, and quantifying coronary calcification • Assist with assessing the need for lesion preparation, stent sizing, minimizing geographic miss, verifying stent expansion, evaluating complications, and identifying causes of stent failure
  • 29.
    OCT/IVUS J Am CollCardiol Img. 2017 Dec, 10 (12) 1487–1503 A B • OCT and IVUS images from the same lesions • Red dotted line: EEL (external elastic lamina) • Yellow dotted line: internal elastic lamina • Blue dotted line: lumen surface • Yellow double arrowhead: (EEL) diameter • White double arrow head: Lumen diameter
  • 30.
    OCT/IVUS J Am CollCardiol Img. 2017 Dec, 10 (12) 1487–1503 A B • (A’) and (A’’) are OCT and IVUS images corresponding to the arrow in (A) in a patient with stable angina who suffered peri-procedural myocardial infarction after stenting • A’: a large lipid rich plaque defined by diffuse border with attenuation by OCT • A’’: a large attenuated plaque defined as echo attenuation without hyperechoic leading edge by IVUS • B (OCT) and B’ (IVUS) show calcified plaque. The thickness of calcium can be measured only by OCT (1.05 mm), and the calcium angle measured 130 degree by both IVUS and OCT.
  • 31.
    J Am CollCardiol Intv 2019;12:1465–78 A B IMAGING MODALITIES
  • 32.
    Circulation. 2022;145:e18–e114. DOI:10.1161/CIR.0000000000001038 A B 2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines
  • 33.
    J. Pers. Med.2022, 12, 1638. DOI: https://doi.org/10.3390/jpm12101638 B Severity Classification
  • 34.
    J. Pers. Med.2022, 12, 1638. DOI: https://doi.org/10.3390/jpm12101638 B Severity Classification
  • 35.
  • 36.
    TECHNIQUES Circ Cardiovasc Interv.2021;14:e009870. DOI: 10.1161/CIRCINTERVENTIONS.120.009870 A B Balloon-Based Devices: • Non-Compliant Balloons • High-Pressure (Dual-Layer) Non-Compliant Balloons • Cutting Balloons • Scoring Balloons • Intravascular Lithotripsy Coronary Atherectomy: • Rotational Atherectomy • Orbital Atherectomy • Laser Atherectomy
  • 37.
    BALLOON COMPLIANCE Hoballah, J.J., Bechara,C.F. (2021) Vascular Reconstructions. Springer, New York, NY. https://doi.org/10.1007/978-1-0716-1089-3_22 B • Balloon compliance: the change in balloon diameter per atmosphere of inflation pressure (“stretchability” of a balloon) → approximately 0.095 mm/atm for semi-compliant balloons, and 0.01 mm/atm for non- compliant balloons • Semi-compliant balloons: • Expand in diameter as the atmospheres increased • May result in a “dog bone” shape as it expands in a lesion • Non-compliant balloons: • Maintain a consistent diameter throughout their length as they inflate, even at high pressures
  • 38.
    NON-COMPLIANT BALLOONS (NCB) Circ CardiovascInterv. 2021;14:e009870. DOI: 10.1161/CIRCINTERVENTIONS.120.009870 B • Single layer • Can be expanded to high pressures (20–24 atm) • Failure: • Eccentric calcium → guidewire bias may direct force toward the non-calcified segments of the artery • Concentric calcium → insufficient force fails to induce calcium fracture • Possible complications: balloon rupture, vessel dissection, or perforation
  • 39.
    Cuculi F, etal. Open Heart 2020;7:e001204. doi:10.1136/openhrt-2019-001204 B
  • 40.
    Cuculi F, etal. Open Heart 2020;7:e001204. doi:10.1136/openhrt-2019-001204 B
  • 41.
    Cuculi F, etal. Open Heart 2020;7:e001204. doi:10.1136/openhrt-2019-001204 B CONCLUSIONS: In simple coronary lesions, predilatation/ postdilatation with NCBs at high pressures appears to be safe and result in better scaffold and stent expansion. Using SCBs only for predilatation might lead to inadequate stent expansion and postdilatation with NCBs might only partially correct this.
  • 42.
    HIGH-PRESSURE NC BALLOONS Circ CardiovascInterv. 2021;14:e009870. DOI: 10.1161/CIRCINTERVENTIONS.120.009870 B • Dual layer • Low profile • Can exert super high pressures on the lesion (35atm rated pressure) • Data for this device are limited to small case series, but all portray a device that is simple to use and effective, with no signal of increased risk • When conventional NCB’s fail → high-pressure NC balloons provide an effective strategy • It remains unclear when this device would be of definitive benefit → lesion selection remains challenging • Potential risk: coronary dissection, perforation, localized wall injury (may provide a substrate for restenosis)
  • 43.
    Catheter Cardiovasc Interv.2010 Jun 1;75(7):1067-73. doi: 10.1002/ccd.22430. B
  • 44.
    Am J Cardiol. 1995 Sep 1;76(7):518-20. doi: 10.1016/s0002-9149(99)80143-x. B
  • 45.
    Cardiovasc Revasc Med.2019 Dec;20(12):1083-1087. doi: 10.1016/j.carrev.2019.02.026. Epub 2019 Mar 1. B
  • 46.
    Cardiovasc Revasc Med.2019 Dec;20(12):1083-1087. doi: 10.1016/j.carrev.2019.02.026. Epub 2019 Mar 1. B RESULTS: Angiographic success was achieved in 97.5%, procedural success in 96.6%. The OPN alone was able to achieve adequate expansion in >90%. 0.9% days MACE were reported. CONCLUSION: The OPN-dedicated high-pressure balloon provides an effective and safe strategy for treatment of severe resistant coronary lesions.
  • 47.
    CUTTING BALLOON Hoballah, J.J., Bechara,C.F. (2021) Vascular Reconstructions. Springer, New York, NY. https://doi.org/10.1007/978-1-0716-1089-3_22 B • First developed in the mid-1980s by Dr. Peter Barath → initially called the Barath Balloon • Composed of a conventional balloon with three or four atherotomes (microsurgical blades) that are mounted longitudinally along the balloon surface • Provides a focused force at low pressure → create controlled incisions along the lesion length → greater vessel compliance + improved stent expansion • Cons: bulky device → difficulty in delivering
  • 48.
    CUTTING BALLOON Hoballah, J.J., Bechara,C.F. (2021) Vascular Reconstructions. Springer, New York, NY. https://doi.org/10.1007/978-1-0716-1089-3_22 B • The diameter of the cutting balloon is selected to approximate a 1.0 : 1.1 ratio (balloon to the reference vessel diameter) → oversizing increases the risk of perforation and rupture • Balloon lengths are often shorter than conventional balloons, usually 15–20 mm • Should be inflated and deflated slowly (generally 1 atm every 2–3 seconds) to avoid damaging their structural integrity • Some authors advocate rotating the balloon and inflating it multiple times to score the lesion
  • 49.
    CUTTING BALLOON Am J Cardiol. 1995 Sep 1;76(7):518-20. doi: 10.1016/s0002-9149(99)80143-x. B Figure 6. Optical coherence tomography (OCT) images of cutting balloon use. A, Pre-percutaneous coronary intervention OCT image deep (0.90 mm) calcific nodule (lower left quadrant) encroaching on vessel lumen. Minimal luminal area in this segment is 3.51 mm2. B, OCT image immediately following 1:1 sized cutting balloon, showing improved minimal luminal area (7.52 mm2) and signs of vessel preparation with balloon-associated dissection evident (at 7 and 9 o’clock).
  • 50.
    J. Pers. Med.2022, 12, 1638. DOI: https://doi.org/10.3390/jpm12101638 B
  • 51.
    J Geriatr Cardiol2014; 11: 44−49. doi: 10.3969/j.issn.1671-5411.2014.01.012 B
  • 52.
    J Geriatr Cardiol2014; 11: 44−49. doi: 10.3969/j.issn.1671-5411.2014.01.012 B CONCLUSIONS: Cutting balloon angioplasty before DES implantation in severely calcified lesions appears to be more efficacies including significantly larger final stent CSA and larger acute lumen gain, without increasing complications during operations and the MACE rate in 6-month.
  • 53.
    J Invasive Cardiol.2015 Sep;27(9):387-91. B
  • 54.
    J Invasive Cardiol.2015 Sep;27(9):387-91. B CONCLUSIONS: A strategy of lesion preparation with RA, POBA, or CBA in HCCL may be associated with similar clinical outcomes in patients undergoing percutaneous intervention with DES. The RA group had a trend toward greater MACE, death, and TLR.
  • 55.
    SCORING BALLOON Circ Cardiovasc Interv.2021;14:e009870. DOI: 10.1161/CIRCINTERVENTIONS.120.009870 B • Consist of a semi-compliant balloon with 3-4 rectangular nitinol-based struts that encircle the balloon in a helical pattern • Mechanistic evolution of the CB: • Reducing the mechanical trauma exerted on the vessel wall → lower risk of dissection • More deliverable
  • 56.
    Cardiovasc Interv Ther.2019 Jul;34(3):242-248. doi: 10.1007/s12928-018-0553-6. Epub 2018 Oct 19. B
  • 57.
    SCORING BALLOON Cardiovasc Interv Ther.2019 Jul;34(3):242-248. doi: 10.1007/s12928-018-0553-6. Epub 2018 Oct 19. B A: Cross-sectional coronary calcification. B: The image shows the thicknesses of the calcifications (520, 470, and 440 µm), and 3 disruption sites can be seen (after modification by scoring balloon). In this case, the coronary calcification angle was 360° and the shape was non-convex
  • 58.
    J. Pers. Med.2022, 12, 1638. DOI: https://doi.org/10.3390/jpm12101638 B
  • 59.
    SCORING BALLOON Int J Cardiol.2016 Oct 15;221:23-31. doi: 10.1016/j.ijcard.2016.07.002. Epub 2016 Jul 4. B
  • 60.
    SCORING BALLOON Int J Cardiol.2016 Oct 15;221:23-31. doi: 10.1016/j.ijcard.2016.07.002. Epub 2016 Jul 4. B
  • 61.
    SCORING BALLOON Int J Cardiol.2016 Oct 15;221:23-31. doi: 10.1016/j.ijcard.2016.07.002. Epub 2016 Jul 4. B
  • 62.
    OUTCOMES Int J Cardiol.2016 Oct 15;221:23-31. doi: 10.1016/j.ijcard.2016.07.002. Epub 2016 Jul 4. B RESULTS: Stent expansion was significantly higher after predilation by a scoring balloon (68.0% vs. 62.1%, p = 0.017) with similar stent lumen eccentricity (0.84 vs. 0.80, p = 0.18). Intimal disruption was induced significantly more frequently (68.0% vs. 38.4%, p = 0.035) and was more extensive in the scoring group (122° vs. 65°, p = 0.038). Adverse clinical events including death, myocardial infarction, and stent thrombosis were not observed up to 9 months after PCI in both groups. CONCLUSIONS: In this randomized study, pretreatment with a scoring balloon enhanced stent expansion partly through induction of intimal disruption
  • 63.
    INTRAVASCULAR LITHOTRIPSY (IVL) J Am CollCardiol Intv 2021;14:1275–92 B • Terminology: Lithotripsy = breaking stones (Greek) • A non-invasive procedure involving the physical destruction of hardened masses like kidney stones or gallstones • Techniques: • Extracorporeal shockwave lithotripsy (ESWL) • Intracorporeal shockwave lithotripsy (ISWL) • Intravascular lithotripsy (IVL)
  • 64.
    B J Am CollCardiol Intv 2021;14:1275–92 MECHANISM
  • 65.
    B J Am CollCardiol Intv 2021;14:1275–92 MECHANISM
  • 66.
    MECHANISM Interventional Cardiology Review2019;14(3):174–81. DOI: https://doi.org/10.15420/icr.2019.18.R1 B • Energy discharged from the spark gap between 2 electrodes → formation of a plasma vapor bubble in the saline/contrast mixture within the balloon → rapidly expanding and collapsing → generates high-amplitude ultrasonic pressure shockwaves → expands spherically outwards from the emitters • Shockwaves creates fracturing effects when encounters tissue with differing acoustic impedances, but travel through (with minimal effect) when encounters tissue with similar acoustic impedance • Acoustic impedance: • Water: 1.500.000 kg/m2/s • Kidney: 1.600.000 kg/m2/s • Muscle: 1.700.000 kg/m2/s • Calcified tissue: 7.800.000 kg/m2/s
  • 67.
    J Am CollCardiol Intv 2021;14:1275–92 B (A) The intravascular lithotripsy (IVL) balloon catheter is positioned across the target lesion (sized with a ratio of 1:1 with the target vessel, advanced over a standard work-horse guidewire) and inflated to 4 atm (B) Emitter spark gap discharge produces compressive shockwaves that emanate spherically outward; vapor bubble formation is contained with the integrated balloon. (C) IVL shockwaves affect superficial and deep calcium (D) After IVL therapy is delivered, the balloon is inflated to 6 atm prior to deflation. IVL SHOCKWAVE GENERATION
  • 68.
    J Am CollCardiol Img 2017;10:897–906 B OCT Characterization of Calcified Lesions and the Effects of Lithoplasty and Stenting (A) OCT cross sections acquired before lithoplasty in 3 different segments of a calcified lesion (B) Post-lithoplasty, there were multiple fractures noted in the same frames (arrows), with an overall increase in the luminal area (C) After implantation of drug-eluting stents, the fractures were noted to become deeper (arrows), with further increase in acute area gain, resulting in favorable stent expansion and apposition.
  • 69.
    JACC: Asia. 2023Apr, 3 (2) 185–197 B (A) Pre-PCI CAG shows significant calcified plaques in RCA (B) Inflated NC balloon shows dog boning indicating unyielding calcified lesion (C) Post-PCI CAG shows fully expanded stent deployed after IVL modification (D) Pre-IVL IVUS imaging shows a superficial 360 degree arch of superficial calcium (E) IVUS post-IVL shows calcified plaque after IVL, which shows fractures.
  • 70.
    JACC: Asia. 2023Apr, 3 (2) 185–197 B (A) Pre-PCI CAG showing diffuse ISR (in-stent restenosis) in RCA (B) Pre-IVL IVUS showing the under-deployed stent and calcified ISR (C) Inflated NC shows under-expansion, indicating an unyielding calcified lesion (D) Post-IVL IVUS shows some expansion of the stent in the lesion (E) The fully expanded stent after IVL (F) Post-PCI CAG showing the fully expanded stents
  • 71.
    J. Pers. Med.2022, 12, 1638. DOI: https://doi.org/10.3390/jpm12101638 B
  • 72.
    J Am CollCardiol Intv. 2021 Jun, 14 (12) 1337–1348 B
  • 73.
    J Am CollCardiol Intv. 2021 Jun, 14 (12) 1337–1348 B
  • 74.
    J Am CollCardiol Intv. 2021 Jun, 14 (12) 1337–1348 B CONCLUSIONS: In the largest cohort of patients treated with coronary IVL assessed to date, coronary IVL safely facilitated successful stent implantation in severely calcified coronary lesions with a high rate of procedural success.
  • 75.
    CORONARY ATHERECTOMY Interventional CardiologyReview 2019;14(3):182–9. DOI:https://doi.org/10.15420/icr.2019.17.R1 B Rotational atherectomy Orbital atherectomy Laser atherectomy
  • 76.
    ROTATIONAL ATHERECTOMY Circ Cardiovasc Interv.2021;14:e009870. DOI: 10.1161/CIRCINTERVENTIONS.120.009870 B • RA uses a diamond encrusted elliptical burr passed into the coronary artery over a specialized 0.009 inch guidewire (Rotawire) • The burr rotates at speeds of 140.000 to 220.000 rpm (monodirectional) and abrades non-elastic, fibro-calcified tissue into small particles (<10 μm) while deflecting off softer elastic tissue • The debris from the lesion passes downstream and cleared by the reticuloendothelial system.
  • 77.
    Interventional Cardiology Review2019;14(3):182–9. DOI:https://doi.org/10.15420/icr.2019.17.R1 B
  • 78.
    ROTATIONAL ATHERECTOMY Circ Cardiovasc Interv.2021;14:e009870. DOI: 10.1161/CIRCINTERVENTIONS.120.009870 B • Historically had increased peri- procedural and post-procedural complications, with complication rates as high as 9.7% • Most complications are common to all PCI procedures • Some risks are unique to RA: • Burr entrapment • RotaWire fracture • No flow/slow flow • Atrio-ventricular block requiring trans-venous pacing
  • 79.
    Interventional Cardiology Review2019;14(3):182–9. DOI:https://doi.org/10.15420/icr.2019.17.R1 B COMPLICATIONS
  • 80.
    Interventional Cardiology Review2019;14(3):182–9. DOI:https://doi.org/10.15420/icr.2019.17.R1 B
  • 81.
    J. Pers. Med.2022, 12, 1638. DOI: https://doi.org/10.3390/jpm12101638 B
  • 82.
    Circulation: Cardiovascular Interventions.2018;11:e007415. DOI: https://doi.org/10.1161/CIRCINTERVENTIONS.118.007415 B
  • 83.
    Circulation: Cardiovascular Interventions.2018;11:e007415. DOI: https://doi.org/10.1161/CIRCINTERVENTIONS.118.007415 B
  • 84.
    Circulation: Cardiovascular Interventions.2018;11:e007415. DOI: https://doi.org/10.1161/CIRCINTERVENTIONS.118.007415 B CONCLUSION: In patients with severely calcified coronary lesions: • Elective RA is feasible in nearly all patients and the acute success rate is superior to modified balloons. • Both approaches (elective RA and balloon plus bailout RA) are equally safe and effective. • Use of RA is no longer associated with excessive LLL (late-lumen-loss) in the era of modern SES.
  • 85.
    ORBITAL ATHERECTOMY Circ Cardiovasc Interv.2021;14:e009870. DOI: 10.1161/CIRCINTERVENTIONS.120.009870 B • A relatively recent advancement in the field of atheroablation • FDA approval in 2013 • Used a burr with a diamond-coated crown that orbits in an elliptical path within the artery • Pass over a specialist 0.014′′ wire (ViperWire) • The crown’s ablates the calcified lumen→ produces smaller particles of debris<2 μm • Unlike RA, there is continuous blood flow through the artery during ablation → potentially reduce the risk of slow-flow/no reflow, decrease thermal injury and obviate the need for the routine use of temporary pacing
  • 86.
    J. Pers. Med.2022, 12, 1638. DOI: https://doi.org/10.3390/jpm12101638 B Eccentrically mounted diamond-coated crown uses centrifugal force to orbit → bidirectional burr (a) one rotational cycle (b) one orbital cycle observed by high-speed camera in axial direction when the crown rotates at 90,000 rpm (c) front and (d) perspective schematic views of the crown rotation and orbiting.
  • 87.
    J. Pers. Med.2022, 12, 1638. DOI: https://doi.org/10.3390/jpm12101638 B MECHANISM OF ACTION DIFFERENTIAL ORBITAL SANDING Crown will only sand the hard components of the plaque Soft components (plaque/tissue) flex away from the crown ORBITAL MECHANISM: Increased speed → Increased centrifugal force Greater centrifugal force → Larger orbital diameter
  • 88.
    ORBITAL ATHERECTOMY Circ Cardiovasc Interv.2021;14:e009870. DOI: 10.1161/CIRCINTERVENTIONS.120.009870 B • The crown’s orbital diameter expands radially with increasing centrifugal force → allows the operator to control the depth of the ablation (by varying the speed of the burr) → avoids the need to change the burr multiple times + increasing procedural efficiency • Owing to the elliptical mechanism of action, OA is contraindicated in vessel diameters <2.5mm due to increased risk of vessel perforation Eccentric head wobbles Cutting head diamonds
  • 89.
    J. Pers. Med.2022, 12, 1638. DOI: https://doi.org/10.3390/jpm12101638 B
  • 90.
    JACC Cardiovasc Interv.2014 May;7(5):510-8. doi: 10.1016/j.jcin.2014.01.158. B
  • 91.
    JACC Cardiovasc Interv.2014 May;7(5):510-8. doi: 10.1016/j.jcin.2014.01.158. B Primary Safety Endpoint
  • 92.
    JACC Cardiovasc Interv.2014 May;7(5):510-8. doi: 10.1016/j.jcin.2014.01.158. B Primary Efficacy Endpoint Conclusions: The ORBIT II coronary OAS trial met both the primary safety and efficacy endpoints by significant margins. Preparation of severely calcified plaque with the OAS not only helped facilitate stent delivery, but improved both acute and 30-day clinical outcomes compared with the outcomes of historic control subjects in this difficult-to-treat patient population.
  • 93.
    LASER ATHERECTOMY Circulation: CardiovascularInterventions. 2021;14. DOI: https://doi.org/10.1161/CIRCINTERVENTIONS.120.010061 B • Excimer laser coronary angioplasty (ELCA) uses a pulse waved, ultraviolet laser catheter to vaporize cadaveric atherosclerotic tissue with minimal thermal damage • Has been available for >25 years for the percutaneous treatment of coronary artery stenoses • Was shown to be effective in coronary lesions poorly treated with balloon angioplasty alone, including aorto-ostial lesions, long calcified lesions, and saphenous vein graft (SVG) lesions. • ELCA is one of the most useful techniques in calcified lesions that are truly uncrossable • Use of ELCA in PCIs has seen an increase, although overall use remains low
  • 94.
    EQUIPMENTS Interventional Cardiology Review,2016;11(1):27–32. DOI: 10.15420/icr.2016:2:2 B The Spectranetics CVX-300 Excimer Laser System: • Pulse generator (A) • Control panel (B) • ELCA catheters (C) • Foot pedal (D)
  • 95.
    MECHANISM Interventional Cardiology Review,2016;11(1):27–32. DOI: 10.15420/icr.2016:2:2 B • Excimer lasers are pulsed gas lasers that use a mixture of a rare gas and halogen as an active medium to generate pulses of short wavelength, high-energy ultraviolet (UV) light. • Tissue ablation is carried out by 3 distinct mechanisms: • Photochemical: UV laser light is absorbed by intra- vascular material and breaks carbon–carbon bonds • Photothermal: UV laser light elevates the temperature of intra-cellular water → cellular rupture and generates a vapour bubble at the catheter tip • Photomechanical: Expansion and implosion of the vapour bubbles disrupts the obstructive intra- vascular material
  • 96.
    LASER CATHETERS Circ CardiovascInterv. 2021;14:e009870. DOI: 10.1161/CIRCINTERVENTIONS.120.009870 B • Catheters comes in sizes of 0.9, 1.4, 1.7, and 2.0mm • Laser catheter size selection is primarily based on: • Severity of the lesion • Reference vessel diameter • Consistency of the target material • The 0.9- and 1.4-mm catheter are most commonly used and can be used in vessels >2.0 mm in diameter through a 6F guiding catheter • The larger diameter laser catheters (1.7, 2.0 mm) are primarily used in straight sections of vessels with a diameter >3.0 mm and require 7F and 8F guiding catheters, respectively. • Passed along a standard 0.014′′ work-horse guidewire → not require dedicated guidewires (that are often more difficult to deliver distally)
  • 97.
    MECHANISM Cardiovascular Revascularization Medicine,https://doi.org/10.1016/j.carrev.2020.10.016 B
  • 98.
    PROS & CONS CircCardiovasc Interv. 2021;14:e009870. DOI: 10.1161/CIRCINTERVENTIONS.120.009870 B • Provides a solution to a variety of problems that may be encountered, including: • Massive intra-coronary thrombus • Uncrossable lesions • Stent under-expansion. • CONS: • Expensive equipment, particularly if only used sparingly for PCI cases • Complexity surrounding its use (for example, operators and staff have to wear additional eye-protection to prevent retinal exposure to UV light)
  • 99.
    J. Pers. Med.2022, 12, 1638. DOI: https://doi.org/10.3390/jpm12101638 B
  • 100.
    Lancet. 1996 Jan13;347(8994):79-84. doi: 10.1016/s0140-6736(96)90209-3. B
  • 101.
    Lancet. 1996 Jan13;347(8994):79-84. doi: 10.1016/s0140-6736(96)90209-3. B OUTCOMES CONCLUSION: ELCA followed by balloon angioplasty provides no benefit additional to balloon angioplasty alone with respect to the initial and long-term clinical and angiographic outcome in the treatment of obstructive coronary artery disease.
  • 102.
    CORONARY ATHERECTOMY Interventional CardiologyReview 2019;14(3):182–9. DOI:https://doi.org/10.15420/icr.2019.17.R1 B
  • 103.
    JACC: Asia. 2023Apr, 3 (2) 185–197 B
  • 104.
    Circ Cardiovasc Interv.2021;14:e009870. DOI: 10.1161/CIRCINTERVENTIONS.120.009870 B
  • 105.
    JACC: Asia. 2023Apr, 3 (2) 185–197 B
  • 106.
    JACC: Asia. 2023Apr, 3 (2) 185–197 B
  • 107.
    Circ Cardiovasc Interv.2021;14:e009870. DOI: 10.1161/CIRCINTERVENTIONS.120.009870 - European Heart Journal Supplements (2023) 25 (Supplement C), C68–C73 B CALCIUM MODIFICATION TREATMENT ALGORITHM
  • 108.
    Catheter Cardiovasc Interv.2020;doi:10.1002/ccd.28994 B
  • 109.
    CONCLUSIONS 1. Coronary arterycalcification represents a major challenge associated with adverse outcomes after PCI 2. To avoid stent failure, optimal plaque preparation of calcified coronary lesions is required 3. Intracoronary imaging and determination of coronary calcification severity and characteristics are the keys to guiding further treatment decisions. 4. Available modification techniques includes: Balloon-Based Devices (Non-Compliant Balloons, High-Pressure Non-Compliant Balloons, Cutting Balloons, Scoring Balloons, Intravascular Lithotripsy) and Coronary Atherectomy (Rotational Atherectomy, Orbital Atherectomy, Laser Atherectomy) 5. The decision relating to which modification technique to use is based on numerous anatomic and technical factors, including the location of the lesion, the concentricity of the calcium pool, operator familiarity/expertise, and local device availability.