Reply to Letter to the Editor for Case Series Entitled “Optimizing Stent Expansion in Calcified Coronary Lesions: A Case Series on the Efficacy of Scoring Balloons for Acute Underexpansion”

We sincerely appreciate the interest and thoughtful comments of Vijayvergiya et al. [1] regarding our case series on the use of scoring balloons for acute stent underexpansion [2]. Their letter raises important points concerning intravascular imaging, lesion preparation, and device selection. We are grateful for the opportunity to clarify our rationale and highlight both areas of agreement and directions for future investigation. We emphasized that scoring balloons should not be regarded solely as predilatation tools but may also serve as effective rescue devices in the acute setting. Despite comprehensive predilatation and high-pressure non-complian balloon post-dilatation, our cases demonstrated persistent underexpansion, particularly in heavily calcified lesions [2]. In such real-world scenarios, scoring balloons facilitated controlled plaque fracture and provided meaningful additional stent expansion, where other options were limited [3]. Three of four patients presented with acute coronary syndromes, in whom urgent revascularization was prioritized over extensive calcium modification (e.g., atherectomy or intravascular lithotripsy). In this context, post-stenting scoring balloon use represented a practical and sometimes lifesaving solution. We stress that we do not advocate bypassing adequate lesion preparation when feasible; rather, our report highlights the utility of scoring balloons as a salvage option when conventional measures fail or advanced devices are unavailable. We fully acknowledge the lack of intravascular imaging (intravascular ultrasound and optical coherence tomography [IVUS/OCT]) as a limitation, which we clearly stated in our manuscript. Intravascular imaging is undoubtedly superior for calcium characterization, device sizing, and confirmation of stent expansion, and we strongly endorse its use whenever possible [4]. However, our series reflects acute settings where imaging was not available and broader contexts where resources remain limited. In such circumstances, we relied on detailed angiographic criteria, which although less precise provided reasonable guidance for identifying underexpansion. We support the view that future studies should integrate IVUS/OCT to refine mechanistic understanding and optimize outcomes. We concur that dedicated calcium-modifying strategies (atherectomy, intravascular lithotripsy, cutting/scoring balloons pre-stenting) remain the preferred approach when conditions allow [5]. In our series, the absence of these tools reflected urgent clinical needs and resource constraints, not lack of awareness. Once a stent is deployed, atherectomy is no longer feasible, and post-stent lithotripsy raises safety concerns. Thus, balloon-based strategies are often the only realistic rescue. Our cases illustrate that scoring balloons can effectively crack resistant plaque beneath an underexpanded stent, yielding significant luminal gain without resorting to more complex interventions. We acknowledge prior reports of complications such as balloon rupture or stent deformation. However, none occurred in our small cohort. All patients experienced smooth in-hospital courses and remained event-free during long-term follow-up (1–3.5 years). These findings support the safety and durability of acute scoring balloon optimization in selected patients, although larger studies are necessary to confirm this profile. In conclusion, we concur with Vijayvergiya et al. [1]. on the importance of intravascular imaging and optimal calcium modification whenever possible. At the same time, our case series highlights the pragmatic value of scoring balloons: they are widely available, cost-effective, and can serve as a safe and effective rescue strategy for acute stent underexpansion, particularly in urgent or resource-limited settings. Future randomized and imaging-guided studies are warranted to better define their role within therapeutic algorithms. The authors have nothing to report. The authors declare no conflicts of interest.