Intracoronary Cryotherapy for Vulnerable Plaque Stabilization

Acute coronary syndromes most commonly arise from rupture of biologically vulnerable, rather than hemodynamically severe, coronary plaques. Advances in intravascular and noninvasive imaging techniques, including intravascular ultrasound, optical coherence tomography, near-infrared spectroscopy, and coronary computed tomography angiography, have enabled precise identification of high-risk plaque features such as thin fibrous caps, large lipid cores, and high plaque burden. While intensive lipid-lowering therapy favorably modifies plaque composition and reduces cardiovascular risk, interventional strategies are needed to directly stabilize nonflow-limiting but biologically vulnerable plaques. Intracoronary cryotherapy has emerged as a novel, investigational approach aimed at modifying plaque biology through controlled thermal modulation without permanent intracoronary implantation. Preclinical studies demonstrate increased fibrous cap thickness and collagen content following cryotherapy, consistent with plaque stabilization. Early first-in-human experience suggests technical feasibility and short-term safety. This review summarizes contemporary approaches to vulnerable plaque identification, existing pharmacologic and interventional strategies, and the evolving role of intracoronary cryotherapy as a potential plaque-directed therapy.