Calcium Modification Techniques in Percutaneous Coronary Intervention: Evidence, Mechanics, Complications and Device Selection

Coronary artery calcification is common in patients undergoing percutaneous coronary intervention (PCI); it impairs device delivery and stent expansion and predicts stent failure. Balloon-based techniques (non-compliant, super high-pressure, cutting and scoring balloons, intravascular lithotripsy), rotational and orbital atherectomy, and excimer laser coronary atherectomy are now widely available. This narrative review describes the mechanism of each technique, the calcium morphology it suits on intravascular imaging, and its advantages and limitations, and synthesizes the randomized trials published between 2018 and 2026, including their longer-term follow-up. Dedicated calcium modification improves procedural success compared with balloon-only strategies in selected calcified lesions, but no trial has shown fewer deaths or myocardial infarctions; the only trial powered for a clinical endpoint comparing preparation strategies found no benefit from routine orbital atherectomy. Head-to-head comparisons were powered for imaging surrogates and mostly found the techniques non-inferior to one another. Intravascular imaging guidance is associated with larger stent areas and fewer adverse events. We also review technique-specific complications and their percutaneous management, and the evidence on performing these procedures in centers without on-site cardiac surgery. Finally, we propose a lesion-based, imaging-guided approach to technique selection and outline the trials still needed.