Devices to Prepare Severely Calcified Lesions: Is There a Difference When Assessed by Intravascular Imaging?

Severely calcified coronary lesions are found in 25% of patients undergoing PCI, and their presence has a negative impact in long term outcomes. These lesions difficult stent expansion and increase device failure rate, even when using the latest generation of drug eluting stents (DES). This is why there is an interest in lesion preparation strategies and the use of intravascular imaging in patients with severe calcified lesions. 

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Two randomized studies have assessed rotational atherectomy (RA) and balloon-based techniques prior DES implantation. The PREPARE-CALC (Comparison of Strategies to Prepare Severely Calcified Coronary Lesions), where the use of RA was more successful when compared against balloons to modify lesions (cutting/scoring balloon), and the ISAR-CALC (Comparison of Strategies to Prepare Severely Calcified Coronary Lesions), where super high-pressure balloons were angiographically superior vs scoring balloons. Both studies used OCT to assess stent expansion and compare groups.

The aim of this study based on the analysis of these two randomized multicenter studies was to compared RA performance and balloon-based techniques (scoring/cutting and high-pressure balloon) before DES implantation, assessed by angiography and OCT. 

Primary end point was stent expansion assessed by OCT. Secondary end point was stent eccentricity, asymmetry, angiographic lumen gain, strategy success and cardiovascular events defined as cardiovascular death, target vessel MI, and repeat revascularization. 

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200 patients were looked at, 63 were treated with RA, 103 with scoring/cutting balloon and 34 with high pressure balloons. Most patients were men, presenting multivessel disease. The artery most frequently treated was the anterior descending, and 40% of cases involved a bifurcation. Lesions treated with RA or scoring/cutting balloon were more calcified and tortuous. 

Lesion preparation with RA, scoring/cutting balloon or high-pressure balloon presented no differences when it came to stent expansion (p= 0.49) and asymmetry (p=0.83). The use of high-pressure balloons was associated to less eccentricity vs. RA or cutting/scoring balloon (p=0.03) with no difference between these last two. Success rate was more often seen with RA vs. scoring/cutting balloon (p=0.002) or high-pressure balloon (p=0.06). There were no differences in clinical outcomes between the groups. 


In patients with severely calcified coronary lesions undergoing DES stenting, lesion preparation with RA, cutting/scoring balloon or high-pressure balloon is associated with similar stent expansion when assessed by OCT. The use of high pressure balloons was associated with less stent eccentricity, while strategy success is most frequent with RA. The clinical impact of these findings require further research. 

Dr. Andrés Rodríguez.
Member of the Editorial board of

Original Title: Rotational Atherectomy or Balloon-Based Techniques to Prepare Severely Calcified Coronary Lesions.

Reference: Tobias Rheude, MD et al J Am Coll Cardiol Intv 2022;15:1864–1874.

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