PCI in the calcified lesion: Difference between revisions
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* Rotational atherectomy in mild-moderate calcifications: In less severly calcified lesion, no differences in restenosis rates were found after paclitaxel-eluting stent implantation in calcified and non calcified vessels (5). | * Rotational atherectomy in mild-moderate calcifications: In less severly calcified lesion, no differences in restenosis rates were found after paclitaxel-eluting stent implantation in calcified and non calcified vessels (5). | ||
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Revision as of 14:08, 20 April 2010
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
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Challenges of Calcified Lesions
- The presence of coronary calcification reduces the compliance of the vessel, and may predispose to dissections at calcified plaque–normal wall interface after balloon angioplasty
- The presence of coronary calcification also reduces the ability to cross chronic total occlusions, and, in severely calcified lesions, stent strut expansion is inversely correlated with the circumferential arc of calcium (1)
- The presence of extensive coronary calcification poses unique challenges for PCI as calcium in the vessel wall leads to irregular and inflexible lumens, and makes the delivery of guidewires, balloons, and stents much more challenging.
- Extensive coronary calcification also renders the vessel wall rigid, necessitating higher balloon inflation pressures to obtain complete stent expansion, and, on occasion, leading to “undilatable” lesions that resist any achievable balloon expansion pressure.
Calcification in Saphenous Vein Grafts (SVGs)
Calcificationes noted within SVGs are generally within the reference vessel wall rather than within the lesion, and are associated with older graft age, insulin –dependent diabetics, and smoking (2)
Angiographic Evaluation
Coronary artery calcium is an important marker for coronary atherosclerosis. Conventional coronary angiography has limited sensitivity for the detection of smaller amounts of calcium, and only moderately sensitive for the detection of extensive lesion calcium (sensitivity 60% and 85% for three- and four-quadrant calcium, respectively) (3).
Treatment
Rotational atherectomy effectively ablates vessel wall calcification and facilitates stent delivery and complete stent expansion
- Rotational atherectomy in severe lesion calcification: Rotational atherectomy is the preferred pretreatment method in patients with severe lesion calcification, particularly ostial lesions, and facilitates the delivery and expansion of coronary stents by creating microdissection planes within the fibrocalcific plaque. Yet even with these contemporary methods, the presence of moderate or severe coronary calcification is associated with reduced procedural success and higher complication rates (4), including stent dislodgement.
- Rotational atherectomy in mild-moderate calcifications: In less severly calcified lesion, no differences in restenosis rates were found after paclitaxel-eluting stent implantation in calcified and non calcified vessels (5).
<biblio>
- ref1 pmid=11170322
</biblio>
<biblio>
- ref2 pmid=15723972
</biblio>
<biblio>
- ref3 pmid=7895353
</biblio>
<biblio>
- ref4 pmid=12127606
</biblio>
<biblio>
- ref5 pmid=16253590
</biblio>