Visualization of coronary artery calcification and its impact on percutaneous coronary intervention procedure (a literature review)
DOI:
https://doi.org/10.14739/2310-1210.2025.1.313820Keywords:
coronary artery calcification, diagnosis, intravascular imaging, treatment, percutaneous coronary intervention, prognosisAbstract
In general, the phenomenon of vascular calcification is quite common and might pose considerable impediments for vascular, cardiovascular and endovascular surgeons, as well as for interventional cardiologists when performing surgical manipulations during the treatment of patients with coronary artery disease (CAD) or peripheral atherosclerosis. A high degree of coronary artery (CA) calcification is independently associated with an increased risk of major cardiovascular events after percutaneous coronary intervention (PCI).
The aim of the work is to analyze modern professional literature, summarize information and add to our ideas about the impact of CA calcification and methods of its visualization on the PCI technical aspects.
Since the second half of the 20th century, various methods that allow for visualization of СA plaque calcification have been developed and introduced into clinical practice. These techniques vary in their potential due to type and technical parameters of the radiation source, possibilities of using specialized software, automation of image analysis, etc. Currently, the methods of intravascular imaging, intravascular ultrasound (IVUS) and optical coherence tomography (OCT), are the most informative for visualization of CA calcification and can help interventionalists when performing PCI to identify and evaluate calcified lesions, to determine the indications and choose an optimal type of device for calcium modification, directing appropriate stent or balloon sizing; to detect signs of suboptimal stent implantation providing control over possible periprocedural complications. In addition, the deposition of such morphological substrate as calcium within coronary atherosclerotic lesions is a predictor of insufficient stent expansion during PCI, which in turn can cause thrombosis and in-stent restenosis. CA lesion preparation before stent implantation involves using specialized angiographic balloons or atherectomy devices. Applying these methods of calcium modification contributes to the compliance of the calcified plaque causing fractures beyond or within the stent, ensures optimal final stent expansion and reduces the risks of possible long-term consequences. Furthermore, other periprocedural difficulties and problems may arise during PCI of calcified CA lesions: increased probability of technical failure due to the impossibility of passing the target lesion with instruments, intimal dissection, wall perforation, distal embolization, etc.
Conclusions. CA calcification is a complex issue for an interventional cardiologist during CA stenting, which certainly complicates the PCI procedure and requires a specialist not only theoretical knowledge, but also practical skills in using a wide range of interventional tools and techniques. There are modern methods of identifying calcified CA lesion and its quantitative assessment. Among them are methods of intravascular visualization – IVUS and OCT, which are used directly in a catheterization laboratory during PCI. They provide the amplest opportunities and the most advanced capabilities for determining the morphological substrate of the affected CA area and allow an interventionist to plan PCI and adjust its real-time implementation at different stages of the procedure. The use of intracoronary imaging methods gives more opportunities to improve PCI outcomes.
References
Copeland-Halperin RS, Baber U, Aquino M, Rajamanickam A, Roy S, Hasan C, et al. Prevalence, correlates, and impact of coronary calcification on adverse events following PCI with newer-generation DES: Findings from a large multiethnic registry. Catheter Cardiovasc Interv. 2018;91(5):859-866. doi: https://doi.org/10.1002/ccd.27204
Blankstein R, Budoff MJ, Shaw LJ, Goff DC Jr, Polak JF, Lima J, et al. Predictors of coronary heart disease events among asymptomatic persons with low low-density lipoprotein cholesterol MESA (Multi-Ethnic Study of Atherosclerosis). J Am Coll Cardiol. 2011;58(4):364-74. doi: https://doi.org/10.1016/j.jacc.2011.01.055
Wang L, Jerosch-Herold M, Jacobs DR Jr, Shahar E, Detrano R, Folsom AR; MESA Study Investigators. Coronary artery calcification and myocardial perfusion in asymptomatic adults: the MESA (Multi-Ethnic Study of Atherosclerosis). J Am Coll Cardiol. 2006;48(5):1018-26. doi: https://doi.org/10.1016/j.jacc.2006.04.089
Wong ND, Kouwabunpat D, Vo AN, Detrano RC, Eisenberg H, Goel M, et al. Coronary calcium and atherosclerosis by ultrafast computed tomography in asymptomatic men and women: relation to age and risk factors. Am Heart J. 1994;127(2):422-30. doi: https://doi.org/10.1016/0002-8703(94)90133-3
Bentzon JF, Otsuka F, Virmani R, Falk E. Mechanisms of plaque formation and rupture. Circ Res. 2014;114(12):1852-66. doi: https://doi.org/10.1161/CIRCRESAHA.114.302721
Nakahara T, Dweck MR, Narula N, Pisapia D, Narula J, Strauss HW. Coronary Artery Calcification: From Mechanism to Molecular Imaging. JACC Cardiovasc Imaging. 2017;10(5):582-93. doi: https://doi.org/10.1016/j.jcmg.2017.03.005
Goodman WG, London G, Amann K, Block GA, Giachelli C, Hruska KA, et al. Vascular calcification in chronic kidney disease. Am J Kidney Dis. 2004;43(3):572-9. doi: https://doi.org/10.1053/j.ajkd.2003.12.005
Ferencik M, Blankstein R, Nasir K. Unravelling the coronary artery calcium paradox: benefits of plaques of stone. Eur Heart J Cardiovasc Imaging. 2019;20(11):1305-6. doi: https://doi.org/10.1093/ehjci/jez043
Criqui MH, Denenberg JO, Ix JH, McClelland RL, Wassel CL, Rifkin DE, et al. Calcium density of coronary artery plaque and risk of incident cardiovascular events. JAMA. 2014;311(3):271-8. doi: https://doi.org/10.1001/jama.2013.282535. Erratum in: JAMA. 2015;313(13):1374. doi: https://doi.org/10.1001/jama.2014.16845
Puri R, Nicholls SJ, Shao M, Kataoka Y, Uno K, Kapadia SR, et al. Impact of statins on serial coronary calcification during atheroma progression and regression. J Am Coll Cardiol. 2015;65(13):1273-82. doi: https://doi.org/10.1016/j.jacc.2015.01.036
Hoffmann R, Mintz GS, Popma JJ, Satler LF, Kent KM, Pichard AD, et al. Treatment of calcified coronary lesions with Palmaz-Schatz stents. An intravascular ultrasound study. Eur Heart J. 1998;19(8):1224-31. doi: https://doi.org/10.1053/euhj.1998.1028
Sharma SK, Tomey MI, Teirstein PS, Kini AS, Reitman AB, Lee AC, et al. North American Expert Review of Rotational Atherectomy. Circ Cardiovasc Interv. 2019;12(5):e007448. doi: https://doi.org/10.1161/CIRCINTERVENTIONS.118.007448
Généreux P, Madhavan MV, Mintz GS, Maehara A, Palmerini T, Lasalle L, et al. Ischemic outcomes after coronary intervention of calcified vessels in acute coronary syndromes. Pooled analysis from the HORIZONS-AMI (Harmonizing Outcomes With Revascularization and Stents in Acute Myocardial Infarction) and ACUITY (Acute Catheterization and Urgent Intervention Triage Strategy) TRIALS. J Am Coll Cardiol. 2014;63(18):1845-54. doi: https://doi.org/10.1016/j.jacc.2014.01.034
Shiode N, Kozuma K, Aoki J, Awata M, Nanasato M, Tanabe K, et al. The impact of coronary calcification on angiographic and 3-year clinical outcomes of everolimus-eluting stents: results of a XIENCE V/PROMUS post-marketing surveillance study. Cardiovasc Interv Ther. 2018;33(4):313-20. doi: https://doi.org/10.1007/s12928-017-0484-7
Kawashima H, Serruys PW, Hara H, Ono M, Gao C, Wang R, et al. 10-Year All-Cause Mortality Following Percutaneous or Surgical Revascularization in Patients With Heavy Calcification. JACC Cardiovasc Interv. 2022;15(2):193-204. doi: https://doi.org/10.1016/j.jcin.2021.10.026
Judkins MP. Selective coronary arteriography. I. A percutaneous transfemoral technic. Radiology. 1967;89(5):815-24. doi: https://doi.org/10.1148/89.5.815
Lee MS, Yang T, Lasala J, Cox D. Impact of coronary artery calcification in percutaneous coronary intervention with paclitaxel-eluting stents: Two-year clinical outcomes of paclitaxel-eluting stents in patients from the ARRIVE program. Catheter Cardiovasc Interv. 2016;88(6):891-7. doi: https://doi.org/10.1002/ccd.26395
Barbato E, Gallinoro E, Abdel-Wahab M, Andreini D, Carrié D, Di Mario C, et al. Management strategies for heavily calcified coronary stenoses: an EAPCI clinical consensus statement in collaboration with the EURO4C-PCR group. Eur Heart J. 2023;44(41):4340-56. doi: https://doi.org/10.1093/eurheartj/ehad342
Hurlock GS, Higashino H, Mochizuki T. History of cardiac computed tomography: single to 320-detector row multislice computed tomography. Int J Cardiovasc Imaging. 2009;25 Suppl 1:31-42. doi: https://doi.org/10.1007/s10554-008-9408-z
Kolesnyk MY. [The role of coronary artery calcium estimation in the primary prevention strategy for cardiovascular diseases]. Zaporozhye medical journal. 2023;25(5):447-54. Ukrainian. doi: https://doi.org/10.14739/2310-1210.2023.5.285583
Hoffmann U, Ferencik M, Cury RC, Pena AJ. Coronary CT angiography. J Nucl Med. 2006;47(5):797-806. Available from: https://jnm.snmjournals.org/content/47/5/797.long
Knuuti J, Wijns W, Saraste A, Capodanno D, Barbato E, Funck-Brentano C, et al. 2019 ESC Guidelines for the diagnosis and management of chronic coronary syndromes. Eur Heart J. 2020;41(3):407-77. doi: https://doi.org/10.1093/eurheartj/ehz425. Erratum in: Eur Heart J. 2020;41(44):4242. doi: https://doi.org/10.1093/eurheartj/ehz825
Sekimoto T, Akutsu Y, Hamazaki Y, Sakai K, Kosaki R, Yokota H, et al. Regional calcified plaque score evaluated by multidetector computed tomography for predicting the addition of rotational atherectomy during percutaneous coronary intervention. J Cardiovasc Comput Tomogr. 2016;10(3):221-8. doi: https://doi.org/10.1016/j.jcct.2016.01.004
Wijns W, Shite J, Jones MR, Lee SW, Price MJ, Fabbiocchi F, et al. Optical coherence tomography imaging during percutaneous coronary intervention impacts physician decision-making: ILUMIEN I study. Eur Heart J. 2015;36(47):3346-55. doi: https://doi.org/10.1093/eurheartj/ehv367
Yock PG, Linker DT, Angelsen BA. Two-dimensional intravascular ultrasound: technical development and initial clinical experience. J Am Soc Echocardiogr. 1989;2(4):296-304. doi: https://doi.org/10.1016/s0894-7317(89)80090-2
Hoang V, Grounds J, Pham D, Virani S, Hamzeh I, Qureshi AM, et al. The Role of Intracoronary Plaque Imaging with Intravascular Ultrasound, Optical Coherence Tomography, and Near-Infrared Spectroscopy in Patients with Coronary Artery Disease. Curr Atheroscler Rep. 2016;18(9):57. doi: https://doi.org/10.1007/s11883-016-0607-0
Wang X, Matsumura M, Mintz GS, Lee T, Zhang W, Cao Y, et al. In Vivo Calcium Detection by Comparing Optical Coherence Tomography, Intravascular Ultrasound, and Angiography. JACC Cardiovasc Imaging. 2017;10(8):869-79. doi: https://doi.org/10.1016/j.jcmg.2017.05.014
Gao XF, Wang ZM, Wang F, Gu Y, Ge Z, Kong XQ, et al. Intravascular ultrasound guidance reduces cardiac death and coronary revascularization in patients undergoing drug-eluting stent implantation: results from a meta-analysis of 9 randomized trials and 4724 patients. Int J Cardiovasc Imaging. 2019;35(2):239-47. doi: https://doi.org/10.1007/s10554-019-01555-3
Cialdella P, Sergi SC, Zimbardo G, Donahue M, Talarico GP, Lombardi d’Aquino UM, et al. Calcified coronary lesions. Eur Heart J Suppl. 2023;25(Suppl C):C68-73. doi: https://doi.org/10.1093/eurheartjsupp/suad009
Kostamaa H, Donovan J, Kasaoka S, Tobis J, Fitzpatrick L. Calcified plaque cross-sectional area in human arteries: correlation between intravascular ultrasound and undecalcified histology. Am Heart J. 1999;137(3):482-8. doi: https://doi.org/10.1016/s0002-8703(99)70496-5
Huang D, Swanson EA, Lin CP, Schuman JS, Stinson WG, Chang W, et al. Optical coherence tomography. Science. 1991;254(5035):1178-81. doi: https://doi.org/10.1126/science.1957169
Jang IK, Bouma BE, Kang DH, Park SJ, Park SW, Seung KB, et al. Visualization of coronary atherosclerotic plaques in patients using optical coherence tomography: comparison with intravascular ultrasound. J Am Coll Cardiol. 2002;39(4):604-9. doi: https://doi.org/10.1016/s0735-1097(01)01799-5
Prati F, Di Vito L, Biondi-Zoccai G, Occhipinti M, La Manna A, Tamburino C, et al. Angiography alone versus angiography plus optical coherence tomography to guide decision-making during percutaneous coronary intervention: the Centro per la Lotta contro l'Infarto-Optimisation of Percutaneous Coronary Intervention (CLI-OPCI) study. EuroIntervention. 2012;8(7):823-9. doi: https://doi.org/10.4244/EIJV8I7A125
Kobayashi Y, Okura H, Kume T, Yamada R, Kobayashi Y, Fukuhara K, et al. Impact of target lesion coronary calcification on stent expansion. Circ J. 2014;78(9):2209-14. doi: https://doi.org/10.1253/circj.cj-14-0108
Vavuranakis M, Toutouzas K, Stefanadis C, Chrisohou C, Markou D, Toutouzas P. Stent deployment in calcified lesions: can we overcome calcific restraint with high-pressure balloon inflations? Catheter Cardiovasc Interv. 2001;52(2):164-72. doi: https://doi.org/10.1002/1522-726x(200102)52:2<164::aid-ccd1041>3.0.co;2-s
Song L, Mintz GS, Yin D, Yamamoto MH, Chin CY, Matsumura M, et al. Characteristics of early versus late in-stent restenosis in second-generation drug-eluting stents: an optical coherence tomography study. EuroIntervention. 2017;13(3):294-302. doi: https://doi.org/10.4244/EIJ-D-16-00787
Räber L, Mintz GS, Koskinas KC, Johnson TW, Holm NR, Onuma Y, et al. 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. 2018;39(35):3281-300. doi: https://doi.org/10.1093/eurheartj/ehy285. Erratum in: Eur Heart J. 2019;40(3):308. doi: https://doi.org/10.1093/eurheartj/ehy460
Fujino A, Mintz GS, Matsumura M, Lee T, Kim SY, Hoshino M, et al. A new optical coherence tomography-based calcium scoring system to predict stent underexpansion. EuroIntervention. 2018;13(18):e2182-e2189. doi: https://doi.org/10.4244/EIJ-D-17-00962
Kang SJ. Intravascular Ultrasound-Derived Criteria for Optimal Stent Expansion and Preprocedural Prediction of Stent Underexpansion. Circ Cardiovasc Interv. 2021;14(10):e011374. doi: https://doi.org/10.1161/CIRCINTERVENTIONS.121.011374
Kubo T, Shimamura K, Ino Y, Yamaguchi T, Matsuo Y, Shiono Y, et al. Superficial Calcium Fracture After PCI as Assessed by OCT. JACC Cardiovasc Imaging. 2015;8(10):1228-9. doi: https://doi.org/10.1016/j.jcmg.2014.11.012
Maejima N, Hibi K, Saka K, Akiyama E, Konishi M, Endo M, et al. Relationship Between Thickness of Calcium on Optical Coherence Tomography and Crack Formation After Balloon Dilatation in Calcified Plaque Requiring Rotational Atherectomy. Circ J. 2016;80(6):1413-9. doi: https://doi.org/10.1253/circj.CJ-15-1059
Fujino A, Mintz GS, Lee T, Hoshino M, Usui E, Kanaji Y, et al. Predictors of Calcium Fracture Derived From Balloon Angioplasty and its Effect on Stent Expansion Assessed by Optical Coherence Tomography. JACC Cardiovasc Interv. 2018;11(10):1015-7. doi: https://doi.org/10.1016/j.jcin.2018.02.004
Allali A, Richardt G, Toelg R, Elbasha K, Sulimov DS, Kastrati A, et al. High-speed rotational atherectomy versus modified balloons for plaque preparation of severely calcified coronary lesions: two-year outcomes of the randomised PREPARE-CALC trial. EuroIntervention. 2023;18(16):e1365-e1367. doi: https://doi.org/10.4244/EIJ-D-22-00677
Mintz GS, Matsumura M, Ali Z, Maehara A. Clinical Utility of Intravascular Imaging: Past, Present, and Future. JACC Cardiovasc Imaging. 2022;15(10):1799-20. doi: https://doi.org/10.1016/j.jcmg.2022.04.026
Downloads
Additional Files
Published
How to Cite
Issue
Section
License
Authors who publish with this journal agree to the following terms:
- Authors retain copyright and grant the journal right of first publication with the work simultaneously licensed under a Creative Commons Attribution License that allows others to share the work with an acknowledgement of the work's authorship and initial publication in this journal.
- Authors are able to enter into separate, additional contractual arrangements for the non-exclusive distribution of the journal's published version of the work (e.g., post it to an institutional repository or publish it in a book), with an acknowledgement of its initial publication in this journal.
- Authors are permitted and encouraged to post their work online (e.g., in institutional repositories or on their website) prior to and during the submission process, as it can lead to productive exchanges, as well as earlier and greater citation of published work (See The Effect of Open Access)
