Cracking (The Code of) Coronary Artery Calcification Towin the Last Battle of Percutaneous Coronary Intervention

Still in the Middle of a Rocky Road

Norihiro Kogame; Patrick W. Serruys; Yoshinobu Onuma


Eur Heart J. 2020;41(6):797-800. 

In This Article

Will Atherectomy or Lithotripsy Solve the Issue of Delayed Healing?

The question remains of whether currently available devices such as cutting balloon, scoring balloon, rotational atherectomy, and lithotripsy for the treatment of calcified plaque prior to stenting could improve the healing after DES implantation. The intravascular atherectomy device (e.g. Rotablator, Orbital, etc.) ablates the surface of the plaque, but does not directly affect the calcification located in the deep layer of the coronary plaque. The removal of the surface of the plaque may result in the exposure of the blood flow to an even greater surface of abrasive calcified matrix than prior to ablation.

So far, two randomized controlled trials comparing rotational atherectomy vs. balloon-based technique for severely calcified lesions demonstrated quite a low incidence of stent thrombosis at 9 months in patients treated with rotational atherectomy before DES implantation (0% in PREPARE-CALC and 0.8% in ROTAXUS), although the number of enrolled patients was small in both trials (n = 200 in PREPARE-CALC and n = 240 in ROTAXUS).[17,18] We await the results of the ongoing ECLIPS trial that will randomize 2000 patients with calcified lesions to either orbital atherectomy or conventional balloon angioplasty as lesion preparation prior to stenting (NCT03108456).

The intravascular lithotripsy catheter could influence the compliance of the calcified vessel by fragmenting superficial and deep calcification. The balloon catheter encompasses multiple lithotripsy emitters. The generated sonic pressure waves selectively crack calcium while minimizing injury and maintaining the integrity of the fibroelastic components of the vessel wall.[13]

The present pathohistological study demonstrated that the superficial calcium was associated with delayed healing; therefore, an intravascular lithotripsy may be theoretically preferable since this technique could crack calcium without exposing deep calcification or creating a severe medial tear. However, this beneficial lithotripsic approach should be demonstrated in the context of clinical randomized trial.