Dear readers,

This group of articles addresses recent data on the interventional treatment of calcified coronary nodules (CN), one of the most challenging subsets of treatable coronary lesions.

There are three known pathophysiological mechanisms for myocardial infarction: plaque rupture, plaque erosion, and calcified nodules (CN). Unsurprisingly, acute coronary syndromes related to CN carry a much worse prognosis, as they are not only technically harder to treat, but they are also associated with worse clinical and anatomical characteristics: higher age, diabetes, renal insufficiency, heart failure, and higher SYNTAX scores.  

Interventional strategies to treat CN include non-compliant balloon angioplasty, specialty balloon angioplasty (cutting, scoring, etc.), drug-coated balloon angioplasty, intravascular lithotripsy (IVL), laser, orbital or rotational atherectomy. The most recent data published in EuroIntervention show that the long-term durability of IVL is maintained and is similar to treated calcified lesions without CN (similar median minimal stent area and stent expansion). The low risk of dissection, perforation, and distal embolization also makes this technology highly favorable.

The application of laser, rotational, or orbital atherectomy to CN depends on their proximity to the wire based on intravascular imaging. Although the ablative effect on CN could theoretically be more pronounced than IVL, this comes at a higher risk of distal embolization, dissection, and perforation. In addition, the presence of thrombus in ACS cases contraindicates rotational and orbital atherectomy.

Best,

Hady Lichaa, MD, FACC, FSCAI, FSVM, RPVI