Page 25 - Read Online

Andò et al. Vessel Plus 2023;7:15 https://dx.doi.org/10.20517/2574-1209.2023.26 Page 7 of 22

Table 1. Devices used for plaque modification of calcified lesions
“Balloon-based” techniques Ablative techniques
Cutting balloon Rotational Atherectomy
• Wolverine, Boston Scientific • Rotablator and ROTAPRO, Boston Scientific
Scoring balloon Orbital Atherectomy
• AngioSculpt, Spectranetics • Diamondback 360° Coronary Orbital Atherectomy System, Cardiovascular Systems
• Scoreflex, OrbusNeich
Very high-pressure non-compliant balloon LASER Atherectomy
• OPN, SIS Medical • CVX-300 ELCA System, Spectranetics
Lithotripsy balloon
• Rx Shockwave, Shockwave Medical

Balloon-based techniques
Theoretically, the first choice for the predilatation of calcified lesions should be a simple non-compliant
balloon, especially in cases where an ablative technique could be unsafe, such as in patients with low left
ventricular ejection fraction (LVEF), with a single patent vessel, or with acute coronary syndrome and a
high thrombotic burden in which distal embolization can have deleterious consequences. Patients with
macroscopic thrombus or dissections visible on angiography are also at greater risk of procedural
complications with atherectomy techniques. Despite the slightly higher profile compared to conventional
semi-compliant balloons, non-compliant balloons are preferred because they are characterized by a more
uniform expansion even at high pressures. This is particularly important in calcific lesions where the
expansion of a semi-compliant balloon at elevated pressures can lead to preferential expansion towards the
point of least resistance of the plaque , where the calcific component is absent, thereby increasing the risk
[44]
of dissection or vessel rupture. There are some specific balloons for extremely fibrotic or calcified lesions
that exert a focal radial expansive force. This translates into even more controlled balloon expansion,
overall, with a good efficacy and safety profile, thus reducing barotrauma and the risk of coronary
dissections and perforations. The Cutting Balloon (Wolverine, Boston Scientific, Natick, MA, USA)
incorporates microsurgical blades arranged longitudinally on its surface and creates incisions in the plaque
upon inflation, allowing for greater lumen gain at lower pressures and with less barotrauma, both in simpler
lesions and in calcified ones . IVUS analysis demonstrated that lesion modification with cutting balloons
[46]
[45]
is associated with a greater reduction of plaque burden and greater lumen gain in calcified lesions compared
with simple balloon angioplasty . Theoretically, scoring balloons (AngioSulpt, Spectranetics, Colorado
[47]
Springs, CO, USA, Scoreflex, OrbusNeich, Hong Kong, China) have a better navigability profile. They have
nitinol metal wires on the surface of the balloon, which facilitate the anchoring of the closed device to the
plaque and determine, upon inflation, incisions in the plaque itself and limit the risk of dissection or
perforation . Furthermore, there are non-compliant very high-pressure balloons (OPN, SIS Medical,
[48]
Frauenfeld, Switzerland), made up of a double-layer structure that allows a rated burst pressure (RBP) of 35
atmospheres. This feature represents a unique option for the effective dilatation of under-expanded
[49]
stents . Data from a recent multicentre observational register have then confirmed its efficacy and ease of
use for the preparation of severely calcified lesions, maintaining an excellent safety profile .
[50]
Rotational atherectomy
Historical perspective
Rotational atherectomy was developed in the pre-stent era as a tool to improve the outcomes of
percutaneous procedures for dilating calcified atherosclerotic lesions. In 1988, Fourrier et al. reported the
first series of RA in humans as a stand-alone therapy or supplemented by balloon dilations . With the
[51]