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Andò et al. Vessel Plus 2023;7:15 https://dx.doi.org/10.20517/2574-1209.2023.26 Page 17 of 22

vessel preparation should be repeated and implemented with, for example, a larger atherectomy burr or a
IVL balloon.

Once the stent has been implanted, it is necessary to check the result with the intravascular imaging catheter
[35]
to verify the optimal expansion and apposition of the stent struts to the vessel wall . Any stent
optimization that may be necessary will be carried out with conventional non-compliant or very high-
pressure balloons. The use of an IVL balloon inside a newly implanted stent in order to optimize stent
apposition by acting on CAC remaining under the stent struts is a technically feasible procedure , even if
[116]
it should currently be considered off-label since it is not known whether the sound pressure waves delivered
against the metal structure and the polymer of the DES can cause any structural alterations .
[117]

CONCLUSIONS
Patients with calcific coronary artery disease represent a subset with a high risk of adverse outcomes, both
intra-procedural and in the long-term. The need to guarantee a targeted and tailored treatment based on the
coronary anatomy of any individual patient is a current priority of the interventional community. The
efficacy of RA in improving procedural success for the treatment of calcified lesions has been widely
demonstrated. The advent of new technologies -and especially of IVL-, the application of techniques and
materials initially developed for as complex procedures as CTO, the increasing experience of contemporary
operators and the introduction of new generation DES with excellent technical and structural properties, are
further contributing to improving outcomes of current PCI for calcific lesions.

DECLARATIONS
Authors’ contributions
Made substantial contributions to the conception and design of the study and wrote the manuscript: Andò
G, Alagna G, De Rosa S, Pelliccia F, Gragnano F, Piccolo R, Moscarella E, Fabris E, Montone RA, Muscoli
S, Spaccarotella C, Niccoli G
Provided administrative and material support and critically reviewed the manuscript: Sinagra G, Indolfi C,
Porto I, Perrone Filardi P, Calabrò P

Availability of data and materials
Not applicable.

Financial support and sponsorship
None.

Conflicts of interest
All authors declared that there are no conflicts of interest.

Ethical approval and consent to participate
Not applicable.

Consent for publication
Not applicable.

Copyright
© The Author(s) 2023.