Coronary artery calcification

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief:  Anahita Deylamsalehi, M.D.[2]Parth Vikram Singh, MBBS[3]

## Overview

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The coronary angiogram is fairly insensitive to the presence of lesion calcification, particularly to the presence of deep vessel wall calcification. Intravascular ultrasound is much more sensitive in the assessment of vessel wall calcification. Conventional coronary angiography has limited sensitivity for the detection of smaller amounts of calcium, and has moderate sensitivity for the detection of extensive lesion calcium (sensitivity 60% and 85% for three- and four-quadrant calcium, respectively). Calcification is often associated with older saphenous vein graft age, insulin–dependent diabetics, and smoking. Calcified lesions pose several challenges to the interventional cardiologists as they are sometimes difficult to cross with the angioplasty equipment, they are less likely to fully dilate, prone to recoil, and often do not allow for full expansion of the stent. Failure to fully expand the stent may result in restenosis. Stents should be deployed only after ensuring that the lesion can be fully expanded by a conventional balloon angioplasty.

## Grading System

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### Angiography based Grading

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* None: no radiopacity.

* Mild: faint radiopacities noted during the cardiac cycles.

* Moderate: dense radiopacities noted only during the cardiac cycle.

* Severe: dense radiopacities noted without cardiac motion before contrast injection generally compromising both sides of the arterial lumen.

### IVUS based Grading

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* In intravascular ultrasound (IVUS), calcium appears as a highly echogenic (bright) structure that causes acoustic shadowing, which limits the ability to assess calcium thickness. This occurs due to complete reflection of ultrasound waves at the calcified interface. For lesion modification prior to percutaneous coronary intervention (PCI), Zhang et al.[1] proposed an IVUS-based scoring system to predict the risk of stent underexpansion and guide the need for calcium modification before stent placement. The scoring system assigns 1 point for each of the following IVUS-detected features:

IVUS-Based Calcium Scoring System (Zhang et al.) Parameter | Threshold | Points

|
|

Maximum Calcium Arc and length  | >270° and ≥5 mm  | 1
Calcium Arc  | 360°  | 1
Presence of a calcified nodule (CN)  | Present  | 1
Vessel diameter  | <3.5 mm  | 1
Total Score | 0–4 | —
Interpretation | Score of ≥2 indicates High risk of stent underexpansion  | —

A total score of ≥2 is associated with a higher risk of stent underexpansion, indicating that pre-stent calcium modification using appropriate devices should be strongly considered.

### OCT based Grading

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* Optical coherence tomography (OCT) can assess not only the arc and length of calcified lesions but also their thickness. Compared to intravascular ultrasound (IVUS), OCT provides greater accuracy in identifying nodular calcium and distinguishing its morphology, whether eruptive or non-eruptive, thus allowing the operator to personalize treatment. For lesion modification prior to percutaneous coronary intervention (PCI), Fujino et al.[2] validated OCT-based scoring system that helps predict the risk of stent underexpansion. The score is calculated based on the following criteria: maximum calcium arc >180° (2 points), maximum thickness >0.5 mm (1 point), and calcium length >5 mm (1 point). A total lesion calcium score of ≥3 indicates a high likelihood of stent underexpansion.

OCT-Based Calcium Scoring System (Fujino et al.) Parameter | Threshold | Points

|
|

Maximum Calcium Arc  | >180°  | 2
Maximum Calcium Thickness  | >0.5 mm  | 1
Calcium Length  | >5 mm  | 1
Total Score | 0–4 | —
Interpretation | Score of ≥3 indicates High risk of stent underexpansion  | —

## Diagnosis

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* The coronary angiogram is fairly insensitive to the presence of lesion calcification, particularly the presence of deep vessel wall calcification.[3]
* Intravascular ultrasound is much more sensitive in the assessment of vessel wall calcification.[4][3]
* Conventional coronary angiography has limited sensitivity for the detection of smaller amounts of calcium, and has moderate sensitivity for the detection of extensive lesion calcium (sensitivity 60% and 85% for three- and four-quadrant calcium, respectively).[4][3]
* Presence of calcium deposit thicker than 500 mm or presence of calcium involving an arc of the vessel >270 degree on intravascular imaging requires lesion modification to facilitate stent delivery.[5]
* Calcification of SVGs is generally within the reference vessel wall rather than within the lesion itself. Calcification is often associated with older graft age, insulin–dependent diabetics, and smoking. [4]

## Treatment

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* Calcified lesions pose several challenges to the interventional cardiologists as they are sometimes difficult to cross with the angioplasty equipment, they are less likely to fully dilate, they are prone to recoil, and they often do not allow for full expansion of the stent. It is critical to notice that failure to fully expand the stent may result in restenosis.[6]
* The following methods could be used to modify calcified lesions:
* Rotational atherectomy
* Orbital atherectomy
* Cutting balloon atherotomy
* Intracoronary lithotripsy
* Angioplasty
* Rotational atherectomy is frequently employed following unsuccessful pre-dilating PTCA to perform plaque modification. Stents should be deployed only after ensuring that the lesion can be fully expanded by a conventional balloon angioplasty.

### Treatment Workflow

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Figure 1. Management algorithm for calcified coronary lesion. DES: drug-eluting stent; LA: excimer laser coronary atherectomy; IVL: intravascular lithotripsy; IVUS: intravascular ultrasound; NC: noncompliant; OA: orbital atherectomy; OCT: optical coherence tomography; PCI: percutaneous coronary intervention; RA: rotational atherectomy

Figure 1 outlines an algorithmic approach for managing calcified coronary lesions, emphasizing intravascular imaging (IVI) as a critical initial step. Accurate diagnosis, characterization, and quantification of calcium via IVUS or OCT not only guide treatment decisions but also improve post-PCI outcomes.[7] For lesions that are uncrossable, primary atheroablative intervention can be used. Superficial calcified lesions should be assessed using calcium scoring to determine the need for adjunctive plaque modification therapies.[8][9][10]

Deep calcified plaques beneath superficial fibrosis can often be treated preferably with non-compliant (NC) or specialty balloons, while intravascular lithotripsy (IVL) can also be used.[11] Among atheroablative options, excimer laser coronary atherectomy (ELCA) may be used to ablate superfiscial fibrous tissue, while rotational atherectomy (RA) has limited efficacy for deep calcium.

The management of calcified nodules (CN) is especially challenging. Differentiating eruptive from non-eruptive CN via intravascular imaging is helpful, as eruptive CN may respond well to IVL as a primary or adjunctive therapy.[12] Orbital atherectomy (OA), due to its circumferential plaque shaving, may offer advantages over RA, though this remains unproven. Highly non-deformable CNs may necessitate combined approaches, with synergy observed when IVL is used alongside other atheroablative strategies like RA or OA to debulk and fracture calcified tissue.

Following plaque modification, repeat intravascular imaging is essential. If calcium fractures are absent, additional therapies should be employed before stent deployment. A combination of RA or OA with IVL appears to be promising. In cases where RA alone does not adequately treat deep calcium or when IVL cannot be used upfront due to device delivery issues, using combination therapy aligns with clinical objectives, particularly achieving extensive plaque modification through maximal debulking. Case series evaluating the RotaTripsy (RA + IVL) have shown promising feasibility and efficacy.[13][14] Similarly, RA combined with cutting balloons may enhance acute luminal gain and stent expansion in select patients.[15]

Once optimal plaque preparation is achieved and drug-eluting stent (DES) is implanted, post-stenting intravascular imaging is performed to assess for edge dissection, strut malapposition, tissue protrusion, geographical miss, and stent underexpansion. For underexpanded stents unresponsive to high-pressure NC ballooning, super-high-pressure NC balloons or IVL can be used.[16][17]

## PCI Complications and Technical Challenges

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### Reduced Compliance of the Vessel

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The presence of coronary calcification reduces the compliance of the vessel, and it may predispose calcified plaque–normal wall interfaces to dissections after balloon angioplasty.

### Reduced Ability to Cross the Lesion

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* The lack of flexibility in calcified arteries makes it difficult to advance balloons and particularly stents down a tortuous vessel. This is often observed in a tortuous and calcified right coronary artery.
* The presence of coronary calcification also reduces the ability to cross chronic total occlusions and severely stenotic lesions.

### Reduced Ability to Fully Dilate the Lesion

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* Stent strut expansion is inversely correlated with the circumferential arc of calcium on intravascular ultrasound. [18]
* Extensive coronary calcification is associated with muscle rigidity requiring higher balloon inflation pressures to obtain complete stent expansion.

## PCI Techniques

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### Guidewire Technique

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Often times hydrophilic guidewires with a core that extends to the tip are necessary to cross heavily calcified lesions. Once the lesion is crossed, then a more flexible and less traumatic wire can be inserted distally to minimize vessel, and to minimize the potential for vessel perforation. If there is the difficulty in delivering the equipment, then a more rigid wire such as a stabilizer wire can be used to facilitate passage of devices. Sometimes two wires are used in the "buddy wire technique" to straighten the vessel and facilitate delivery of devices.

### Balloon Dilation

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Calcified plaques usually require higher balloon pressures to fully expand than normal plaques. Because of this, non-compliant balloons may be a better choice than compliant or semi-compliant balloons. Differential expansion of compliant or semi-compliant balloons inside a particular lesion may jeopardize less diseased segments if the balloon expands greater than the vessel's native diameter. On the contrary, non-compliant balloons allow for a more uniform expansion at high pressures and therefore may be a better choice to apply focused pressure at the calcified plaque. Another option is to place a second "buddy" wire adjacent to the balloon to improve the ability to dilate calcified plaque.

If pre-dilatation fails to fully expand a calcified stenosis, then the risks and benefits of stent deployment should be carefully considered due to the risk of incomplete expansion and future restenosis.

### Intravascular Ultrasound (IVUS)

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IVUS is a medical imaging methodology that uses a specially designed catheter with a miniaturized ultrasound probe attached to the distal end of the catheter. The proximal end of the catheter is attached to computerized ultrasound equipment. It allows the application of ultrasound technology to see from inside blood vessels out through the surrounding blood column, visualizing the endothelium (inner wall) of blood vessels in living individuals. IVUS is used in the coronary arteries to determine the amount of atheromatous plaque built up at any particular point in the epicardial coronary artery.

While coronary angiography by fluroscopy is limited in its detection and severity assessment of coronary calcification, IVUS can assess the extent of calcification and may be particularly useful for instances when the reason for poor balloon expansion is uncertain. Although this approach has its advantages over angiography, heavy involvement of superficial, sub-endothelial calcification may require rotational atherectomy.

### Cutting Balloon and FX MiniRailTM

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A cutting balloon is an angioplasty device used in percutaneous coronary interventions. It has a special balloon tip with small blades, that are activated when the balloon is inflated. This procedure is different from rotational atherectomy, in which a diamond tipped device spins at high revolutions to cut away calcific (chalky) atheroma usually prior to coronary stenting.

This technique can be useful in treating calcified lesions because the microsurgical blades on the surface of the balloon may help to score and modify calcified plaques. Generally, if a cutting balloon will cross the lesion, a stent can be delivered. Although this technique has its advantages, there are certain additional considerations that must be made before deciding to use this procedure. For one, despite their usefulness, these balloons are often more difficult to deliver past tortuous or calcified segments, so extra care must be used. Also, there were no significant differences observed in rates of restenosis when using this procedure.

### Rotational Atherectomy

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Rotational atherectomy is an invasive method of removing plaque and blockages from an artery and subsequently widening arteries that have been narrowed by arterial disease. Unlike angioplasty and stents of blocked arteries that simply push blockages aside into the wall of the artery, rotational atherectomy involves inserting a thin catheter with a rotating blade on its end into the artery. The rotating edge is used to remove plaque buildups, thereby opening the artery and restoring normal blood flow.

Rotational atherectomy is frequently employed following unsuccessful pre-dilating PTCA to perform plaque modification. This procedure facilitates PTCA by creating micro-fractures, removing calcified plaque, and increasing vessel compliance. Despite its usefulness in treating calcified lesions, certain precautions should be taken. In an effort to limit the risk of vessel laceration, smaller diameter burrs are now preferred. A general guideline to use is that the initial burr to luminal ratio should be 1:2. Additional caution should be taken when a coronary dissection is present, as rotational atherectomy may propagate the dissection.

* Rotational atherectomy in severe lesion calcification: Rotational atherectomy is the preferred pretreatment method in patients with severe lesion calcification, particularly ostial lesions, and facilitates the delivery and expansion of coronary stents by creating microdissection planes within the fibrocalcific plaque. Yet even with these contemporary methods, the presence of moderate or severe coronary calcification is associated with reduced procedural success and higher complication rates[19], including stent dislodgement.

* Rotational atherectomy in mild-moderate calcifications: In less severely calcified lesions, no differences in restenosis rates were found after paclitaxel-eluting stent implantation in calcified and non-calcified vessels. [20]

Caution should be used in the patient with a low ejection fraction as distal embolization from rotational atherectomy can result in a decline and LV function. Also, tortuous segments with acute bends should not be treated with rotational atherectomy is there is an increased risk of vessel dissection at the site of acute bends and turns.

### Directional Coronary Atherectomy (DCA)

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DCA involves inserting a thin, flexible catheter with a small blade on its end into the artery, which cuts off plaque buildups. These plaque shavings are caught with the catheter and are subsequently removed from the artery.[21]

One problem that may arise during the procedure is that heavy calcification proximal to the target lesion may limit deliverability of the device and its success.

### Excimer Laser Coronary Atherectomy/Angioplasty (ECLA)

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ECLA uses a laser, instead of a traditional blade, to perform atherectomy and angioplasty. The excimer laser is a pulsed ultraviolet laser that can erode calcified plaque while also causing minimal thermal tissue injury.[22]

One advantage of using ELCA is that it fractures calcified plaques, thereby facilitating PTCA. However, it also has a higher equipment cost and has a lesser ease of use than rotational atherectomy. Furthermore, it is more commonly used in lower extremity peripheral arterial disease than in coronary artery disease (CAD).

### Orbital Atherectomy

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Orbital atherectomy (OA) is an adjunctive percutaneous coronary intervention (PCI) technique developed to optimize stent delivery and expansion in patients with heavily calcified coronary lesions. The system features a single, eccentrically mounted diamond-coated crown that orbits along a dedicated guidewire, generating centrifugal force to selectively ablate rigid, inelastic tissue such as calcified or fibrotic plaque, while preserving healthy, compliant vessel walls. Unlike rotational atherectomy (RA), the OA crown orbits rather than spins and is effective during both forward and backward passes. This procedure produces microparticulate debris typically less than 2 μm, smaller than the 5–10 μm particles seen with RA, which may lower the risk of distal embolization. A lubricant solution composed of soybean oil, egg yolk phospholipids, glycerin, sodium hydroxide, and water helps minimize heat and friction between the rotating shaft and the guidewire. In procedures involving the right coronary artery (RCA) or a left-dominant circumflex artery (LCx), temporary pacemaker placement may be considered prophylactically.

OA is indicated for the treatment of de novo, severely calcified coronary artery lesions to facilitate stent delivery. Contraindications include inability to pass the guidewire, presence of lesions within bypass grafts, previously stented segments, or the last remaining conduit, as well as angiographically visible thrombus or dissection. Severe vessel tortuosity—particularly at lesion entry or exit points—constitutes a relative contraindication. The clinical efficacy and safety of OA are supported by the ORBIT I and ORBIT II trials. ORBIT I, a prospective, nonrandomized feasibility study involving 50 patients,[23] reported 98% device success and 94% procedural success, with major adverse events in 4% of patients in-hospital, 6% at 30 days, and 8% at 6 months. ORBIT II, a larger prospective multicenter trial of 443 patients with severely calcified lesions,[24] demonstrated a 97.7% success rate for stent delivery, with slow flow/no-reflow occurring in <1% of cases, and in-hospital myocardial infarction, target vessel revascularization, and cardiac death all occurring in ≤0.7% of patients. Based on these findings, the 2021 AHA/ACC/SCAI guidelines granted OA a Class IIb recommendation for improving procedural outcomes in fibrotic or heavily calcified lesions.[25]

OA is associated with a relatively low incidence of adverse events.[26][26][27][28] Potential complications include bradycardia—particularly during RCA or dominant LCx interventions—along with coronary dissection, slow or no-reflow, and the rare but serious risk of coronary perforation. In ORBIT II, post-procedural complications directly related to OA occurred in only 0.9% of cases, and the overall procedural complication rate was 1.8% (8 of 443 patients), highlighting the relative safety and clinical utility of this technique.

### Intravascular lithotripsy

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Intravascular lithotripsy (IVL) is a novel balloon-based technology designed to treat severely calcified coronary lesions by adapting principles from urologic lithotripsy for vascular application. It uses a semi-compliant balloon that delivers sonic pressure waves generated by the vaporization of a saline-contrast mixture inside the balloon. This process creates rapidly expanding and collapsing bubbles that emit circumferential waves of approximately 50 atmospheres, effectively disrupting both intimal and medial calcium through compressive forces.[29] These waves also trigger cavitation bubble collapse and promote fracture progression from micro- to macro-level by fatigue mechanism, enabling effective plaque modification while minimizing soft tissue trauma and avoiding direct debulking, which in turn reduces the risk of distal embolization.[30]

The Shockwave IVL system is FDA-approved for use in de novo, severely calcified coronary lesions prior to stent implantation. While off-label use in cases of in-stent restenosis due to under-expanded stent has been described, supporting evidence remains limited.[31] The device is contraindicated for stent delivery and use in carotid or cerebrovascular arteries.

The efficacy and safety of IVL have been established through the DISRUPT CAD I, II, and III trials.[31][32][33]

DISRUPT CAD I (60 patients) and CAD II (120 patients) demonstrated acute luminal gains of 1.7 mm and 1.6 mm, respectively, with 30-day MACE rates of 5.0% and 7.6%. DISRUPT CAD III, the largest study with 431 patients, confirmed an acute gain of 1.7 mm and MACE rates of 7.8% at 30 days and 13.8% at one year. Procedural success exceeded 92% across all studies, with low complication rates and no reports of vessel perforation, slow flow, or no reflow. As a result, the 2021 ACC/AHA/SCAI guidelines issued a Class IIb recommendation for IVL in fibrotic or calcified lesions, on par with other plaque modification techniques such as orbital atherectomy, laser atherectomy, and cutting balloons.[34]

Although IVL generally has a favorable safety profile, it may still lead to typical PCI-related complications, including dissection, perforation, or abrupt vessel closure. A distinctive phenomenon termed “shocktopics”, atrial or ventricular ectopic has been observed during IVL therapy especially in bradycardic patients.[35] In DISRUPT CAD III, this occurred in 41.1% of cases and was associated with a higher rate of intraprocedural hypotension (40.5% vs. 24.5%, p = .0007), though no sustained arrhythmias or adverse events were reported.

### Stents

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In cardiology, a stent is a tube that is inserted into an artery to counteract significant decreases in vessel diameter by acutely propping it open.

In the treatment of calcified lesions, stents are frequently used in conjunction with PTCA or atherectomy to decrease the risk of restenosis. Extra care should be taken in deploying stents in lesions where incomplete expansion occurs following pre-dilation, as incomplete expansion of a target lesion will increase the likelihood of restenosis. Stents should be deployed only after ensuring full balloon expansion.

## 2011 ACCF/AHA/SCAI Guidelines for Percutaneous Coronary Intervention (DO NOT EDIT)[36]

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### Calcified Lesions (DO NOT EDIT)[36]

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Class IIa

"1. Rotational atherectomy is reasonable for fibrotic or heavily calcified lesions that might not be crossed by a balloon catheter or adequately dilated before stent implantation.[37][38][39] (Level of Evidence: C)"

## ACA 2021 Revascularization Guideline

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Class 2a Recommendation, Level of Evidence: B-R[6]

Plaque modification with rotational atherectomy could be helpful in improving procedural success in patients with fibrotic or heavily calcified lesions.
Class 2b Recommendation, Level of Evidence: B-NR [6]

Plaque modification with orbital atherectomy, balloon atherotomy, laser angioplasty, or intracoronary lithotripsy might be helpful in improving procedural success in patients with fibrotic or heavily calcified lesions.

## References

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1. ↑ Zhang M, Matsumura M, Usui E, Noguchi M, Fujimura T, Fall KN, Zhang Z, Nazif TM, Parikh SA, Rabbani LE, Kirtane AJ, Collins MB, Leon MB, Moses JW, Karmpaliotis D, Ali ZA, Mintz GS, Maehara A (October 2021). "Intravascular Ultrasound-Derived Calcium Score to Predict Stent Expansion in Severely Calcified Lesions". Circ Cardiovasc Interv. 14 (10): e010296. doi:10.1161/CIRCINTERVENTIONS.120.010296. PMID 34665658 Check `|pmid=` value (help).
2. ↑ Fujino A, Mintz GS, Matsumura M, Lee T, Kim SY, Hoshino M, Usui E, Yonetsu T, Haag ES, Shlofmitz RA, Kakuta T, Maehara A (April 2018). "A new optical coherence tomography-based calcium scoring system to predict stent underexpansion". EuroIntervention. 13 (18): e2182–e2189. doi:10.4244/EIJ-D-17-00962. PMID 29400655.
3. ↑ 3.0 3.1 3.2 Mintz GS, Popma JJ, Pichard AD; et al. (1995). "Patterns of calcification in coronary artery disease. A statistical analysis of intravascular ultrasound and coronary angiography in 1155 lesions". Circulation. 91 (7): 1959–65. PMID 7895353. Unknown parameter `|month=` ignored (help)CS1 maint: Explicit use of et al. (link) CS1 maint: Multiple names: authors list (link)
4. ↑ 4.0 4.1 4.2 Castagna MT, Mintz GS, Ohlmann P; et al. (2005). "Incidence, location, magnitude, and clinical correlates of saphenous vein graft calcification: an intravascular ultrasound and angiographic study". Circulation. 111 (9): 1148–52. doi:10.1161/01.CIR.0000157160.69812.55. PMID 15723972. Unknown parameter `|month=` ignored (help)CS1 maint: Explicit use of et al. (link) CS1 maint: Multiple names: authors list (link)
5. ↑ Mehanna E, Abbott JD, Bezerra HG (2018). "Optimizing Percutaneous Coronary Intervention in Calcified Lesions: Insights From Optical Coherence Tomography of Atherectomy". Circ Cardiovasc Interv. 11 (5): e006813. doi:10.1161/CIRCINTERVENTIONS.118.006813. PMID 29743161.CS1 maint: Multiple names: authors list (link)
6. ↑ 6.0 6.1 6.2 Writing Committee Members. Lawton JS, Tamis-Holland JE, Bangalore S, Bates ER, Beckie TM; et al. (2022). "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 Am Coll Cardiol. 79 (2): e21–e129. doi:10.1016/j.jacc.2021.09.006. PMID 34895950 Check `|pmid=` value (help).CS1 maint: Multiple names: authors list (link)
7. ↑ Lee JM, Choi KH, Song YB, Lee JY, Lee SJ, Lee SY, Kim SM, Yun KH, Cho JY, Kim CJ, Ahn HS, Nam CW, Yoon HJ, Park YH, Lee WS, Jeong JO, Song PS, Doh JH, Jo SH, Yoon CH, Kang MG, Koh JS, Lee KY, Lim YH, Cho YH, Cho JM, Jang WJ, Chun KJ, Hong D, Park TK, Yang JH, Choi SH, Gwon HC, Hahn JY (May 2023). "Intravascular Imaging-Guided or Angiography-Guided Complex PCI". N Engl J Med. 388 (18): 1668–1679. doi:10.1056/NEJMoa2216607. PMID 36876735 Check `|pmid=` value (help).
8. ↑ Zhang M, Matsumura M, Usui E, Noguchi M, Fujimura T, Fall KN, Zhang Z, Nazif TM, Parikh SA, Rabbani LE, Kirtane AJ, Collins MB, Leon MB, Moses JW, Karmpaliotis D, Ali ZA, Mintz GS, Maehara A (October 2021). "Intravascular Ultrasound-Derived Calcium Score to Predict Stent Expansion in Severely Calcified Lesions". Circ Cardiovasc Interv. 14 (10): e010296. doi:10.1161/CIRCINTERVENTIONS.120.010296. PMID 34665658 Check `|pmid=` value (help).
9. ↑ Räber L, Mintz GS, Koskinas KC, Johnson TW, Holm NR, Onuma Y, Radu MD, Joner M, Yu B, Jia H, Meneveau N, de la Torre Hernandez JM, Escaned J, Hill J, Prati F, Colombo A, di Mario C, Regar E, Capodanno D, Wijns W, Byrne RA, Guagliumi G (September 2018). "Clinical use of intracoronary imaging. Part 1: guidance and optimization of coronary interventions. An expert consensus document of the European Association of Percutaneous Cardiovascular Interventions". Eur Heart J. 39 (35): 3281–3300. doi:10.1093/eurheartj/ehy285. PMID 29790954.
10. ↑ Fujino A, Mintz GS, Matsumura M, Lee T, Kim SY, Hoshino M, Usui E, Yonetsu T, Haag ES, Shlofmitz RA, Kakuta T, Maehara A (April 2018). "A new optical coherence tomography-based calcium scoring system to predict stent underexpansion". EuroIntervention. 13 (18): e2182–e2189. doi:10.4244/EIJ-D-17-00962. PMID 29400655.
11. ↑ Shlofmitz RA, Galougahi KK, Jeremias A, Shlofmitz E, Thomas SV, Ali ZA (October 2022). "Calcium Modification in Percutaneous Coronary Interventions". Interv Cardiol Clin. 11 (4): 373–381. doi:10.1016/j.iccl.2022.06.001. PMID 36243483 Check `|pmid=` value (help).
12. ↑ Ali ZA, Kereiakes D, Hill J, Saito S, Di Mario C, Honton B, Gonzalo N, Riley R, Maehara A, Matsumura M, Stone GW, Shlofmitz R (May 2023). "Safety and Effectiveness of Coronary Intravascular Lithotripsy for Treatment of Calcified Nodules". JACC Cardiovasc Interv. 16 (9): 1122–1124. doi:10.1016/j.jcin.2023.02.015. PMID 37029020 Check `|pmid=` value (help).
13. ↑ Safian RD, Feldman T, Muller DW, Mason D, Schreiber T, Haik B, Mooney M, O'Neill WW (June 2001). "Coronary angioplasty and Rotablator atherectomy trial (CARAT): immediate and late results of a prospective multicenter randomized trial". Catheter Cardiovasc Interv. 53 (2): 213–20. doi:10.1002/ccd.1151. PMID 11387607.
14. ↑ Gonzálvez-García A, Jiménez-Valero S, Galeote G, Moreno R, López de Sá E, Jurado-Román A (February 2022). ""RotaTripsy": Combination of Rotational Atherectomy and Intravascular Lithotripsy in Heavily Calcified Coronary Lesions: A Case Series". Cardiovasc Revasc Med. 35: 179–184. doi:10.1016/j.carrev.2021.04.011. PMID 33903037 Check `|pmid=` value (help).
15. ↑ Allali A, Toelg R, Abdel-Wahab M, Hemetsberger R, Kastrati A, Mankerious N, Traboulsi H, Elbasha K, Rheude T, Landt M, Geist V, Richardt G (November 2022). "Combined rotational atherectomy and cutting balloon angioplasty prior to drug-eluting stent implantation in severely calcified coronary lesions: The PREPARE-CALC-COMBO study". Catheter Cardiovasc Interv. 100 (6): 979–989. doi:10.1002/ccd.30423. PMID 36262074 Check `|pmid=` value (help).
16. ↑ Sardella G, Stefanini G, Leone PP, Boccuzzi G, Fovero NT, Van Mieghem N, Giacchi G, Escaned J, Fineschi M, Testa L, Valenti R, Di Mario C, Briguori C, Cortese B, Ribichini F, Oreglia JA, Colombo A, Sangiorgi G, Barbato E, Sonck J, Ugo F, Trani C, Castriota F, Paggi A, Porto I, Tomai F, Mancone M (July 2023). "Coronary Lithotripsy as Elective or Bail-Out Strategy After Rotational Atherectomy in the Rota-Shock Registry". Am J Cardiol. 198: 1–8. doi:10.1016/j.amjcard.2023.04.032. PMID 37182254 Check `|pmid=` value (help).
17. ↑ Tovar Forero MN, Sardella G, Salvi N, Cortese B, di Palma G, Werner N, Aksoy A, Escaned J, Salazar CH, Gonzalo N, Ugo F, Cavallino C, Sheth TN, Kardys I, Van Mieghem NM, Daemen J (September 2022). "Coronary lithotripsy for the treatment of underexpanded stents: the international & multicentre CRUNCH registry". EuroIntervention. 18 (7): 574–581. doi:10.4244/EIJ-D-21-00545. PMC 10241293 Check `|pmc=` value (help). PMID 35318955 Check `|pmid=` value (help).
18. ↑ Vavuranakis M, Toutouzas K, Stefanadis C, Chrisohou C, Markou D, Toutouzas P (2001). "Stent deployment in calcified lesions: can we overcome calcific restraint with high-pressure balloon inflations?". Catheter Cardiovasc Interv. 52 (2): 164–72. PMID 11170322. Unknown parameter `|month=` ignored (help)CS1 maint: Multiple names: authors list (link)
19. ↑ Wilensky RL, Selzer F, Johnston J; et al. (2002). "Relation of percutaneous coronary intervention of complex lesions to clinical outcomes (from the NHLBI Dynamic Registry)". Am. J. Cardiol. 90 (3): 216–21. PMID 12127606. Unknown parameter `|month=` ignored (help)CS1 maint: Explicit use of et al. (link) CS1 maint: Multiple names: authors list (link)
20. ↑ Moussa I, Ellis SG, Jones M; et al. (2005). "Impact of coronary culprit lesion calcium in patients undergoing paclitaxel-eluting stent implantation (a TAXUS-IV sub study)". Am. J. Cardiol. 96 (9): 1242–7. doi:10.1016/j.amjcard.2005.06.064. PMID 16253590. Unknown parameter `|month=` ignored (help)CS1 maint: Explicit use of et al. (link) CS1 maint: Multiple names: authors list (link)
21. ↑ http://www.lvhn.org/lvh/Your_LVH/Health_Care_Services/Heart_Care_MIMS/Most_Advanced_Treatments|3487
22. ↑ Cook SL, Eigler NL, Shefer A, Goldenberg T, Forrester JS, Litvack F (1991). "Percutaneous excimer laser coronary angioplasty of lesions not ideal for balloon angioplasty". Circulation. 84 (2): 632–43. PMID 1860207. Unknown parameter `|month=` ignored (help)CS1 maint: Multiple names: authors list (link)
23. ↑ Parikh K, Chandra P, Choksi N, Khanna P, Chambers J (June 2013). "Safety and feasibility of orbital atherectomy for the treatment of calcified coronary lesions: the ORBIT I trial". Catheter Cardiovasc Interv. 81 (7): 1134–9. doi:10.1002/ccd.24700. PMID 23460596.
24. ↑ Chambers JW, Feldman RL, Himmelstein SI, Bhatheja R, Villa AE, Strickman NE, Shlofmitz RA, Dulas DD, Arab D, Khanna PK, Lee AC, Ghali MG, Shah RR, Davis TP, Kim CY, Tai Z, Patel KC, Puma JA, Makam P, Bertolet BD, Nseir GY (May 2014). "Pivotal trial to evaluate the safety and efficacy of the orbital atherectomy system in treating de novo, severely calcified coronary lesions (ORBIT II)". JACC Cardiovasc Interv. 7 (5): 510–8. doi:10.1016/j.jcin.2014.01.158. PMID 24852804.
25. ↑ Lawton JS, Tamis-Holland JE, Bangalore S, Bates ER, Beckie TM, Bischoff JM, Bittl JA, Cohen MG, DiMaio JM, Don CW, Fremes SE, Gaudino MF, Goldberger ZD, Grant MC, Jaswal JB, Kurlansky PA, Mehran R, Metkus TS, Nnacheta LC, Rao SV, Sellke FW, Sharma G, Yong CM, Zwischenberger BA (January 2022). "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". Circulation. 145 (3): e18–e114. doi:10.1161/CIR.0000000000001038. PMID 34882435 Check `|pmid=` value (help).
26. ↑ 26.0 26.1 Koifman E, Garcia-Garcia HM, Kuku KO, Kajita AH, Buchanan KD, Steinvil A, Rogers T, Bernardo NL, Lager R, Gallino RA, Ben-Dor I, Pichard AD, Torguson R, Gai J, Satler LF, Waksman R (April 2018). "Comparison of the Efficacy and Safety of Orbital and Rotational Atherectomy in Calcified Narrowings in Patients Who Underwent Percutaneous Coronary Intervention". Am J Cardiol. 121 (8): 934–939. doi:10.1016/j.amjcard.2017.12.041. PMID 29452688.
27. ↑ Goel S, Pasam RT, Chava S, Gotesman J, Sharma A, Malik BA, Frankel R, Shani J, Gidwani U, Latib A (March 2020). "Orbital atherectomy versus rotational atherectomy: A systematic review and meta-analysis". Int J Cardiol. 303: 16–21. doi:10.1016/j.ijcard.2019.12.037. PMID 31898984.
28. ↑ Barrett C, Warsavage T, Kovach C, McGuinn E, Plomondon ME, Armstrong EJ, Waldo SW (February 2021). "Comparison of rotational and orbital atherectomy for the treatment of calcific coronary lesions: Insights from the VA clinical assessment reporting and tracking (CART) program". Catheter Cardiovasc Interv. 97 (2): E219–E226. doi:10.1002/ccd.28971. PMID 32449836 Check `|pmid=` value (help).
29. ↑ Kereiakes DJ, Virmani R, Hokama JY, Illindala U, Mena-Hurtado C, Holden A, Hill JM, Lyden SP, Ali ZA (June 2021). "Principles of Intravascular Lithotripsy for Calcific Plaque Modification". JACC Cardiovasc Interv. 14 (12): 1275–1292. doi:10.1016/j.jcin.2021.03.036. PMID 34167671 Check `|pmid=` value (help).
30. ↑ Dini CS, Tomberli B, Mattesini A, Ristalli F, Valente S, Stolcova M, Meucci F, Baldereschi G, Fanelli F, Shlofmitz RA, Ali ZA, Di Mario C (October 2019). "Intravascular lithotripsy for calcific coronary and peripheral artery stenoses". EuroIntervention. 15 (8): 714–721. doi:10.4244/EIJ-D-18-01056. PMID 31062700.
31. ↑ Brinton TJ, Ali ZA, Hill JM, Meredith IT, Maehara A, Illindala U, Lansky A, Götberg M, Van Mieghem NM, Whitbourn R, Fajadet J, Di Mario C (February 2019). "Feasibility of Shockwave Coronary Intravascular Lithotripsy for the Treatment of Calcified Coronary Stenoses". Circulation. 139 (6): 834–836. doi:10.1161/CIRCULATIONAHA.118.036531. PMID 30715944.
32. ↑ Ali ZA, Nef H, Escaned J, Werner N, Banning AP, Hill JM, De Bruyne B, Montorfano M, Lefevre T, Stone GW, Crowley A, Matsumura M, Maehara A, Lansky AJ, Fajadet J, Di Mario C (October 2019). "Safety and Effectiveness of Coronary Intravascular Lithotripsy for Treatment of Severely Calcified Coronary Stenoses: The Disrupt CAD II Study". Circ Cardiovasc Interv. 12 (10): e008434. doi:10.1161/CIRCINTERVENTIONS.119.008434. PMID 31553205.
33. ↑ Hill JM, Kereiakes DJ, Shlofmitz RA, Klein AJ, Riley RF, Price MJ, Herrmann HC, Bachinsky W, Waksman R, Stone GW (December 2020). "Intravascular Lithotripsy for Treatment of Severely Calcified Coronary Artery Disease". J Am Coll Cardiol. 76 (22): 2635–2646. doi:10.1016/j.jacc.2020.09.603. PMID 33069849 Check `|pmid=` value (help).
34. ↑ Lawton JS, Tamis-Holland JE, Bangalore S, Bates ER, Beckie TM, Bischoff JM, Bittl JA, Cohen MG, DiMaio JM, Don CW, Fremes SE, Gaudino MF, Goldberger ZD, Grant MC, Jaswal JB, Kurlansky PA, Mehran R, Metkus TS, Nnacheta LC, Rao SV, Sellke FW, Sharma G, Yong CM, Zwischenberger BA (January 2022). "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". Circulation. 145 (3): e18–e114. doi:10.1161/CIR.0000000000001038. PMID 34882435 Check `|pmid=` value (help).
35. ↑ Hill JM, Kereiakes DJ, Shlofmitz RA, Klein AJ, Riley RF, Price MJ, Herrmann HC, Bachinsky W, Waksman R, Stone GW (December 2020). "Intravascular Lithotripsy for Treatment of Severely Calcified Coronary Artery Disease". J Am Coll Cardiol. 76 (22): 2635–2646. doi:10.1016/j.jacc.2020.09.603. PMID 33069849 Check `|pmid=` value (help).
36. ↑ 36.0 36.1 Levine GN, Bates ER, Blankenship JC, Bailey SR, Bittl JA, Cercek B, Chambers CE, Ellis SG, Guyton RA, Hollenberg SM, Khot UN, Lange RA, Mauri L, Mehran R, Moussa ID, Mukherjee D, Nallamothu BK, Ting HH (2011). "2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention: Executive Summary A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Society for Cardiovascular Angiography and Interventions" (PDF). Journal of the American College of Cardiology. 58 (24): 2550–83. doi:10.1016/j.jacc.2011.08.006. PMID 22070837. Retrieved 2011-12-08. Text "PDF" ignored (help); Unknown parameter `|month=` ignored (help)CS1 maint: Multiple names: authors list (link)
37. ↑ Moussa I, Di Mario C, Moses J, Reimers B, Di Francesco L, Martini G, Tobis J, Colombo A (1997). "Coronary stenting after rotational atherectomy in calcified and complex lesions. Angiographic and clinical follow-up results". Circulation. 96 (1): 128–36. PMID 9236427. Retrieved 2011-12-15. Unknown parameter `|month=` ignored (help)CS1 maint: Multiple names: authors list (link)
38. ↑ Vaquerizo B, Serra A, Miranda F, Triano JL, Sierra G, Delgado G, Puentes A, Mojal S, Brugera J (2010). "Aggressive plaque modification with rotational atherectomy and/or cutting balloon before drug-eluting stent implantation for the treatment of calcified coronary lesions". Journal of Interventional Cardiology. 23 (3): 240–8. doi:10.1111/j.1540-8183.2010.00547.x. PMID 20636844. Retrieved 2011-12-15. Unknown parameter `|month=` ignored (help)CS1 maint: Multiple names: authors list (link)
39. ↑ Brogan WC, Popma JJ, Pichard AD, Satler LF, Kent KM, Mintz GS, Leon MB (1993). "Rotational coronary atherectomy after unsuccessful coronary balloon angioplasty". The American Journal of Cardiology. 71 (10): 794–8. PMID 8456756. Unknown parameter `|month=` ignored (help); `|access-date=` requires `|url=` (help)CS1 maint: Multiple names: authors list (link)

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Coronary Angiography

Coronary Anatomy|

Normal coronary anatomy • Anomalous origins of coronary arteries
(Left coronary artery • Right coronary artery) • Congenital abnormalities of coronary arteries • Coronary artery segments • Cinefilm frame speed • Coronary artery dominance (Left dominance • Right dominance • Co-dominance)

TIMI Flow Grade|

TIMI flow grade 0 • TIMI flow grade 1 • TIMI flow grade 2 • TIMI flow grade 3

TIMI Frame Count|

TFC for SVG • TIMI Myocardial Frame Count • Washout TIMI Frame Count

TIMI Myocardial Perfusion Grade|

TIMI MPG 0 • TIMI MPG 1 • TIMI MPG 2 • TIMI MPG 3

Thrombus Grading|

Thrombus Grade 0 • Thrombus Grade 1 • Thrombus Grade 2 • Thrombus Grade 3 • Thrombus Grade 4 • Thrombus Grade 5 • Thrombus Grade 6

Lesion Complexity|

Type A • Type B1 • Type B2 • Type C

Dissection Classification|

Type A • Type B • Type C • Type D • Type E • Type F

Coronary Collaterals|

Grade 0 • Grade 1 • Grade 2 • Grade 3 • Rentrop and Cohen’s Collateral Classification

Lesion Morphology|

Myocardial bridge •Definitions of Preprocedural Lesion Morphology • Luminal irregularities • Disease extent • Arterial foreshortening • Infarct related artery (Culprit lesion) • Reocclusion • Restenosis • Degenerated saphenous vein graft • Coronary artery fistula

Angiographic complications|

Distal embolization • Coronary spasm • Abrupt closure • Side branch loss • Slow flow • No-reflow • Pulsatile flow • Flow deceleration • Ectasia • Intimal flap • Staining •

Performing Coronary Angiography|

Patient preparation • Catheter selection • Standard angiographic views • High risk groups • Patients with special need • Access site closure (Manual compression • Assisted compression • Closure devices) •

Quantitative Coronary Angiography (QCA)|

Minimal lumen diameter • Percent stenosis • Reference diameter • Lesion length • Residual stenosis • Average reference segment diameter • Plaque area • Plaque volume •

Contrast Media|

High-osmolar contrast media • Iso-osmolar contrast media • Low-osmolar contrast media

Left Ventriculography & Aortography|

Ejection fraction • Aortography • Quantitative Left Ventricular Analysis (LAO projection • RAO projection • LVA) • Left Ventricular Wall Motion Analysis (Normokinesia • Hypokinesia • Akinesia • Dyskinesia • Aneurysm) • Evaluation of mitral regurgitation • Evaluation of aortic regurgitation

Right Heart Catheterization|

Pressure waveforms (Right atrial pressure • Rirght ventricular pressure • Pulmonary artery pressure • Pulmonary artery wedge-pressure) • Endomyocardial biopsy

Complications|

Access site complications • Dumping • Contrast hypersensitivity • Contrast induced nephropathy • Hypotension • Hypertension • Dissection • Vessel perforation • Acute myocardial infarction • Ventricular fibrillation • Cardiac arrest • Stroke • ASD • VSD • Pulmonary emboli • Myocardial rupture • Peripheral arterial emboli • Radiation injury

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