Balancing innovation and safety in percutaneous treatment of coronary artery calcification

Coronary artery calcification (CAC) is an independent predictor of adverse outcomes in percutaneous coronary intervention (PCI). Under-preparation of calcified plaque predisposes to stent under-expansion, mal-apposition, restenosis, and stent thrombosis, while over-aggressive debulking strategies carry risk of dissection, perforation, and no-reflow. The interventional armamentarium for calcium modification has expanded from high-pressure and non-high pressure specialty balloons including intravascular lithotripsy (IVL) to dedicated atherectomy devices i.e., rotational atherectomy (RA), orbital atherectomy (OA), and excimer laser coronary atherectomy (ELCA), each with a distinct mechanism, evidence base, and risk profile. Additionally, comprehensive assessment of coronary calcium is central to guiding lesion preparation and selecting treatment strategy, with IVUS and OCT providing detailed intravascular characterisation, and CT emerging as a complementary non-invasive tool for procedural planning. Appropriate procedural planning and judicious selection of calcium-modification tools are paramount to maximising procedural safety, minimising complications, and improving clinical outcomes. This review summarizes the pathophysiology of CAC, describes each modification technique, synthesizes the pivotal and recent randomised evidence, outlines current guideline position, and proposes a practical framework for balancing procedural innovation against patient safety. Current evidence supports an individualized, imaging-guided approach to calcium modification. Balloon-based strategies, IVL, atherectomy, and ELCA each have specific strengths and limitations, and no modality has demonstrated universal superiority across lesion subsets. Atherectomy and laser remain important for selected uncrossable, undilatable, or highly resistant lesions, whereas IVL and specialty balloons may provide effective alternatives in appropriately selected crossable lesions. Evidence for many technologies is stronger for procedural and imaging endpoints than for long-term clinical outcomes.