How to identify and prepare calcified lesions safely and effectively

Calcified coronary lesions pose significant challenges in percutaneous coronary intervention, which can impede device placement and stent expansion, thus leading to suboptimal clinical outcomes. This paper outlines a comprehensive approach for the safe and effective preparation of calcified lesions. It emphasizes the importance of pre-procedural planning using either coronary artery calcium scoring or computed tomography coronary angiography, as well as advanced intravascular imaging techniques with intravascular ultrasound and optical coherence tomography for accurate lesion assessment. Various lesion modification strategies are reviewed, including balloon angioplasty, rotational atherectomy, orbital atherectomy, laser atherectomy, and lithotripsy. The selection criteria for each technique based on the lesion characteristics, calcium morphology, and operator experience are discussed. Additionally, clinical data is analysed to provide evidence-based recommendations for practice. The paper concludes with a discussion on future directions and innovations alongside a proposed algorithm for the management of calcified coronary lesions, which is aimed at improving patient outcomes through technological advancements and refined procedural techniques.