Management of severely calcified lesions -Intravascular imaging-guided percutaneous coronary intervention

Percutaneous coronary intervention (PCI) for severely calcified coronary lesions remains challenging, as extensive calcification frequently hampers adequate lesion preparation and optimal stent expansion, thereby increasing the risk of procedural complications and adverse clinical outcomes. The management of these complex lesions continues to require careful procedural planning. Intravascular imaging (IVI), including intravascular ultrasound and optical coherence tomography/optical frequency domain imaging, provides detailed insights into coronary calcium morphology. IVI has become an important tool in contemporary PCI. IVI allows comprehensive evaluation of calcium characteristics such as arc, longitudinal length, thickness, depth, and surface morphology. These findings are closely related to lesion compliance and subsequent stent expansion. The information from IVI facilitates appropriate selection and optimization of calcium modification strategies, including conventional balloons, atherectomy devices, and intravascular lithotripsy. Furthermore, IVI enables assessment of procedural effectiveness by confirming plaque modification, calcium fracture, and stent expansion, while also identifying imaging features associated with an increased risk of vessel injury, dissection, or slow flow. However, each imaging modality has inherent limitations, and careful interpretation of imaging findings is essential, particularly in severely calcified lesions. In this review, we summarize current concepts of IVI-based assessment of coronary calcification and discuss practical considerations for device selection and lesion preparation in severely calcified lesions. Integrating intravascular imaging into PCI may contribute to more tailored treatment strategies and improved clinical outcomes in patients with severely calcified coronary artery disease.