Calcified coronary artery disease: pathophysiology, intracoronary imaging assessment, and plaque modification techniques

Calcified coronary artery disease poses a number of challenges to the interventional cardiologist when performing percutaneous coronary interventions, and patients with calcified coronary artery disease continue to have poorer outcomes at both the short and the long-term follow up. Stent underexpansion is the most feared outcome when performing percutaneous coronary interventions in these patients and is a strong predictor of stent failure. Therefore, intracoronary imaging to guide calcium modification is an important step in the treatment of this disease. The following review outlines a stepwise approach using intracoronary imaging in the assessment of coronary calcification, and in the selection of the appropriate calcium modification tool. Additionally, we describe current calcium modification techniques available, the evidence behind their use, their mechanism of action, and the typical results seen on intracoronary imaging.