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| | #Redirect [[Coronary artery calcification#Treatment]] |
| {{WikiDoc Cardiology Network Infobox}}
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| {{CMG}}<br/>
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| '''Associate Editors-In-Chief:''' John N. Mafi, M.D.; Randall K. Harada, M.D.; Thomas Tu, M.D.; Brian C. Bigelow, M.D.
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| == Challenges of Calcified Lesions ==
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| * 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
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| * 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. <ref name="pmid11170322">{{cite journal |author=Vavuranakis M, Toutouzas K, Stefanadis C, Chrisohou C, Markou D, Toutouzas P |title=Stent deployment in calcified lesions: can we overcome calcific restraint with high-pressure balloon inflations? |journal=Catheter Cardiovasc Interv |volume=52 |issue=2 |pages=164–72 |year=2001 |month=February |pmid=11170322 |doi= |url=}}</ref>
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| * 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.
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| * 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.
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| '''Calcification in Saphenous Vein Grafts (SVGs)'''
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| Calcifications 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. <ref name="pmid15723972">{{cite journal |author=Castagna MT, Mintz GS, Ohlmann P, ''et al.'' |title=Incidence, location, magnitude, and clinical correlates of saphenous vein graft calcification: an intravascular ultrasound and angiographic study |journal=Circulation |volume=111 |issue=9 |pages=1148–52 |year=2005 |month=March |pmid=15723972 |doi=10.1161/01.CIR.0000157160.69812.55 |url=}}</ref>
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| == Angiographic Evaluation ==
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| 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). <ref name="pmid7895353">{{cite journal |author=Mintz GS, Popma JJ, Pichard AD, ''et al.'' |title=Patterns of calcification in coronary artery disease. A statistical analysis of intravascular ultrasound and coronary angiography in 1155 lesions |journal=Circulation |volume=91 |issue=7 |pages=1959–65 |year=1995 |month=April |pmid=7895353 |doi= |url=}}</ref> | |
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| == Treatment ==
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| There are a variety of diagnostic and treatment options for calcified lesions, but better early outcomes may be achieved by using a multi-device interventional strategy.
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| ===Intravascular Ultrasound (IVUS)===
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| [[IVUS|Intravascular Ultrasound]] is a [[medical imaging]] methodology using a specially designed [[catheter]] with a miniaturized [[ultrasound]] probe attached to the distal end the catheter. The proximal end of the [[catheter]] is attached to computerized [[ultrasound]] equipment. It allows the application of [[ultrasound]] technology to see from inside [[blood vessel]]s out through the surrounding [[blood]] column, visualizing the [[endothelium]] (inner wall) of [[blood vessel]]s in living individuals. IVUS is used in the coronary arteries to determine the amount of [[atheroma|atheromatous plaque]] built up at any particular point in the epicardial coronary artery.
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| While coronary angiography by [[fluroscopy]] is limited in its detection and severity assessment of coronary calcification, IVUS can assess the extent of calcification and may be particularly useful for instances when the reason for poor balloon expansion is uncertain. Although this approach has its advantages over angiography, heavy involvement of superficial, sub-endothelial calcification may require [[rotational atherectomy]].
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| ===Rotational Atherectomy===
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| [[Rotational atherectomy]] is a minimally invasive method of removing plaque and blockage from an [[artery]] in the body and subsequently widening arteries narrowed by arterial disease. It falls under the umbrella category of [[percutaneous]] [[revascularization]], which refers to a variety of methods normally used in coronary arteries to restore [[circulation]] to the lower extremities. Unlike [[angioplasty]] and [[stents]] of blocked arteries that simply push blockages aside into the wall of the artery, atherectomy involves inserting a thin catheter with a scraping blade into the artery. The plaque buildups are removed, opening the artery and restoring normal blood flow.
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| [[Rotational atherectomy]] creates micro-fractures, removes calcified plaque, and increases vessel compliance, thereby facilitating [[Percutaneous transluminal coronary angioplasty|PTCA]]. Despite its usefulness in treating calcified lesions, certain precautions should be taken. In an effort to limit the risk of vessel [[laceration]], smaller diameter [[Burr (cutter)|burrs] are now recommended. A general guideline to use is that the initial burr:luminal ratio should be 1:2. Additional caution should be taken when a coronary [[dissection]] is present, as rotational atherectomy may propagate the dissection.
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| * '''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<ref name="pmid12127606">{{cite journal |author=Wilensky RL, Selzer F, Johnston J, ''et al.'' |title=Relation of percutaneous coronary intervention of complex lesions to clinical outcomes (from the NHLBI Dynamic Registry) |journal=Am. J. Cardiol. |volume=90 |issue=3 |pages=216–21 |year=2002 |month=August |pmid=12127606 |doi= |url=}}</ref>, including stent dislodgement.
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| * '''Rotational atherectomy in mild-moderate calcifications:''' In less severely calcified lesion, no differences in restenosis rates were found after paclitaxel-eluting stent implantation in calcified and non calcified vessels. <ref name="pmid16253590">{{cite journal |author=Moussa I, Ellis SG, Jones M, ''et al.'' |title=Impact of coronary culprit lesion calcium in patients undergoing paclitaxel-eluting stent implantation (a TAXUS-IV sub study) |journal=Am. J. Cardiol. |volume=96 |issue=9 |pages=1242–7 |year=2005 |month=November |pmid=16253590 |doi=10.1016/j.amjcard.2005.06.064 |url=}}</ref>
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| ==References==
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| <references/>
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