Balancing innovation and safety in percutaneous treatment of coronary artery calcification
6 affiliations
- 1Department of Cardiology, University Hospitals of Northamptonshire, Kettering General Hospital
- 2Department of Cardiology, University Hospitals of Leicester NHS Trust
- 3Yorkshire Heart Centre, Teaching Hospitals NHS Trust, University of Leeds
- 4Department of Cardiology, Hammersmith Hospital, Imperial College Healthcare NHS Trust
- 5Department of Cardiology, Derriford Hospital, University Hospitals Plymouth
- 6Department of Cardiology, Cleveland Clinic
Abstract
Coronary artery calcification (CAC) is an independent predictor of adverse outcomes in percutaneous coronary intervention (PCI). Under-preparation of calcified plaque predisposes to stent under-expansion, mal-apposition, restenosis, and stent thrombosis, while over-aggressive debulking strategies carry risk of dissection, perforation, and no-reflow. The interventional armamentarium for calcium modification has expanded from high-pressure and non-high pressure specialty balloons including intravascular lithotripsy (IVL) to dedicated atherectomy devices i.e., rotational atherectomy (RA), orbital atherectomy (OA), and excimer laser coronary atherectomy (ELCA), each with a distinct mechanism, evidence base, and risk profile. Additionally, comprehensive assessment of coronary calcium is central to guiding lesion preparation and selecting treatment strategy, with IVUS and OCT providing detailed intravascular characterisation, and CT emerging as a complementary non-invasive tool for procedural planning. Appropriate procedural planning and judicious selection of calcium-modification tools are paramount to maximising procedural safety, minimising complications, and improving clinical outcomes. This review summarizes the pathophysiology of CAC, describes each modification technique, synthesizes the pivotal and recent randomised evidence, outlines current guideline position, and proposes a practical framework for balancing procedural innovation against patient safety. Current evidence supports an individualized, imaging-guided approach to calcium modification. Balloon-based strategies, IVL, atherectomy, and ELCA each have specific strengths and limitations, and no modality has demonstrated universal superiority across lesion subsets. Atherectomy and laser remain important for selected uncrossable, undilatable, or highly resistant lesions, whereas IVL and specialty balloons may provide effective alternatives in appropriately selected crossable lesions. Evidence for many technologies is stronger for procedural and imaging endpoints than for long-term clinical outcomes.
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BibTeX
@article{helal2026balancing,
title = {{Balancing innovation and safety in percutaneous treatment of coronary artery calcification}},
author = {Ayman Helal and Andrew Ladwiniec and Abdul Mozid and Iqbal Malik and Neil Ruparelia and Mohsin Farooq and F. Aaysha Cader and Javed Ehtisham and Prashanth Raju and Naeem Shaukat and Bhavik Shah and Girish Viswanathan and Bernard Prendergast},
journal = {Frontiers in Cardiovascular Medicine},
year = {2026},
month = oct,
doi = {10.3389/fcvm.2026.1964987},
url = {https://www.frontiersin.org/articles/10.3389/fcvm.2026.1964987/full},
note = {CC BY 4.0},
}
RIS
TY - JOUR
TI - Balancing innovation and safety in percutaneous treatment of coronary artery calcification
AU - Ayman Helal
AU - Andrew Ladwiniec
AU - Abdul Mozid
AU - Iqbal Malik
AU - Neil Ruparelia
AU - Mohsin Farooq
AU - F. Aaysha Cader
AU - Javed Ehtisham
AU - Prashanth Raju
AU - Naeem Shaukat
AU - Bhavik Shah
AU - Girish Viswanathan
AU - Bernard Prendergast
PY - 2026
DA - 2026/10/27
JO - Frontiers in Cardiovascular Medicine
DO - 10.3389/fcvm.2026.1964987
UR - https://www.frontiersin.org/articles/10.3389/fcvm.2026.1964987/full
AB - Coronary artery calcification (CAC) is an independent predictor of adverse outcomes in percutaneous coronary intervention (PCI). Under-preparation of calcified plaque predisposes to stent under-expansion, mal-apposition, restenosis, and stent thrombosis, while over-aggressive debulking strategies carry risk of dissection, perforation, and no-reflow. The interventional armamentarium for calcium modification has expanded from high-pressure and non-high pressure specialty balloons including intravascular lithotripsy (IVL) to dedicated atherectomy devices i.e., rotational atherectomy (RA), orbital atherectomy (OA), and excimer laser coronary atherectomy (ELCA), each with a distinct mechanism, evidence base, and risk profile. Additionally, comprehensive assessment of coronary calcium is central to guiding lesion preparation and selecting treatment strategy, with IVUS and OCT providing detailed intravascular characterisation, and CT emerging as a complementary non-invasive tool for procedural planning. Appropriate procedural planning and judicious selection of calcium-modification tools are paramount to maximising procedural safety, minimising complications, and improving clinical outcomes. This review summarizes the pathophysiology of CAC, describes each modification technique, synthesizes the pivotal and recent randomised evidence, outlines current guideline position, and proposes a practical framework for balancing procedural innovation against patient safety. Current evidence supports an individualized, imaging-guided approach to calcium modification. Balloon-based strategies, IVL, atherectomy, and ELCA each have specific strengths and limitations, and no modality has demonstrated universal superiority across lesion subsets. Atherectomy and laser remain important for selected uncrossable, undilatable, or highly resistant lesions, whereas IVL and specialty balloons may provide effective alternatives in appropriately selected crossable lesions. Evidence for many technologies is stronger for procedural and imaging endpoints than for long-term clinical outcomes.
SN - 2297-055X
ER -