Calcified Nodules and Their Treatment with Rotational Atherectomy

Calcified nodules (CN) represent one of the most complex phenotypes to treat in coronary intervention. They are mainly associated with the need for repeat revascularization of the treated lesion, primarily due to protrusion of calcified fragments, stent malapposition, or underexpansion. Rotational atherectomy (RA) has traditionally been used in lesions with severe calcification, although its specific benefit in CN remains unclear according to previous studies.

The aim of the study was to evaluate the impact of RA on the need for target lesion revascularization and to determine which IVUS-derived morphological characteristics could modify its efficacy in complex coronary pathology with calcified nodules.

An analysis of the Japanese multicenter U-SCAN registry was performed, including patients with CN identified by IVUS who underwent percutaneous coronary intervention (PCI). A total of 209 patients with de novo lesions were included; among them, 37.8% were treated with RA. The primary endpoint was target lesion revascularization (TVR) during follow-up. The mean follow-up was 2.1 years.

Patients treated with RA had a lower frequency of acute coronary syndromes (ACS) and exhibited more severe angiographic calcification. In the IVUS analysis, this group also showed more complex lesions (greater maximum calcium arc, larger CN arc, higher percentage of area stenosis, and higher prevalence of adjacent circumferential calcification and contralateral calcification). Despite this greater anatomical complexity, RA achieved a larger final lumen and greater acute lumen gain.

Read also: C-TRACT: Endovascular therapy in post-thrombotic syndrome due to iliac obstruction.

Regarding the primary endpoint, the incidence of TVR was 25.3% in patients treated with rotational atherectomy compared to 31.5% in those without this strategy (log-rank p=0.040). In the adjusted analysis, RA was independently associated with a lower rate of TVR (adjusted HR 0.48; 95% CI: 0.28–0.84; p=0.010).

Independent predictors of higher revascularization risk included a greater percentage of area stenosis, longer calcified nodule length, the presence of adjacent circumferential calcification, and a lower final minimum lumen area (MLA).

Read also: Coil embolization of segmental arteries as a spinal cord protection strategy prior to complex endovascular repair of thoracoabdominal aorta.

When evaluated according to morphology, not all CN showed the same response to RA. In the subgroup with contralateral calcification, RA significantly reduced TVR, with an incidence of 8.6% vs 51.6% (interaction p<0.001). In contrast, in the absence of this characteristic, no clear benefit was observed (38.6% vs 25.3%; p=0.11).

Conclusions:

This subanalysis of the U-SCAN registry shows that, in patients with calcified nodules, rotational atherectomy is associated with a significant reduction in target lesion revascularization during long-term follow-up, being more effective in the subgroup with CN and contralateral calcification. Therefore, appropriate characterization using intravascular imaging could optimize outcomes by guiding a more suitable therapeutic strategy.

Original Title: Enhanced Efficacy of Rotational Atherectomy for Calcified Nodules With Contralateral Calcification: Insights From a Multicenter Intravascular Ultrasound Imaging Study.

Reference: Yabumoto N, Fujino M, Kiyoshige E, Sugane H, Hosoda H, Kitahara S, Fujino Y, Mitsui K, Murai K, Iwai T, Sawada K, Matama H, Honda S, Nakao K, Yoneda S, Takagi K, Asaumi Y, Ogata S, Nishimura K, Kawai K, Tsujita K, Noguchi T, Kataoka Y. Enhanced Efficacy of Rotational Atherectomy for Calcified Nodules With Contralateral Calcification: Insights From a Multicenter Intravascular Ultrasound Imaging Study. Circ Cardiovasc Interv. 2026 Apr;19(4):e015932. doi: 10.1161/CIRCINTERVENTIONS.125.015932. Epub 2026 Feb 11. PMID: 41669840; PMCID: PMC13098656.