Comparison of different calcium modification strategies for coronary calcified nodules: insights from optical coherence tomography

Abstract Background The optimal treatment strategy for coronary calcified nodules (CN) remains uncertain. Purpose We sought to compare the safety and efficacy of different calcium modification strategies for managing CN using optical coherence tomography (OCT). Methods In this single-center retrospective cohort study, consecutive patients undergoing OCT-guided percutaneous coronary intervention (PCI) for severely calcified lesions using rotational atherectomy (RA), orbital atherectomy (OA), or intravascular lithotripsy (IVL) between January 2017 and December 2022 were included. OCT analysis was performed through our institutional core-laboratory to identify CN, assess plaque characteristics, and evaluate post-stent optimization. Primary outcomes were minimum stent area (MSA) and MSA at CN site post-PCI. One-year target vessel failure (TVF), defined as a composite of cardiac death, target-vessel myocardial infarction, or ischemia-driven target vessel revascularization, was also recorded. Results Among a total of 154 patients with 158 lesions, CN was identified in 54 lesions (34.2%) and managed with RA (39%, n=21), OA (33%, n=18), or IVL (28%, n=15). The IVL group exhibited a larger minimal lumen diameter, maximum calcium arc, and maximum calcium thickness at baseline. Post-PCI OCT demonstrated comparable MSA (RA: 5.91 ± 0.33mm², OA: 5.94 ± 0.38mm², IVL: 6.46 ± 0.45mm²; p=0.61) and MSA at CN site (6.77 ± 0.49mm², 6.71 ± 0.51mm², 7.13 ± 0.59mm², respectively; p=0.87) after adjusting for procedural and morphologic factors among the groups. The incidence of TVF at one year was similar among the groups. Conclusions In patients undergoing PCI for severely calcified lesions with CN, comparable procedural and clinical outcomes can be achieved using RA, OA, or IVL. The equivalence across these techniques underscores a role for individualized decision-making integrating patient- and lesion-specific characteristics, as well as center expertise when selecting a treatment strategy for CN.OCT findings and clinical outcomes