Management of Calcified Blockages in the Coronary Arteries

Calcified coronary blockages are increasing due to lifestyle and health factors. Advanced angioplasty technologies now help break hard plaques, making treatment safer and more effective.

As we know, coronary artery blockages were earlier mostly caused by cholesterol deposition and were soft in nature. In such cases, simple, plain balloons were used during angioplasty to open up the blockage effectively. But of late, especially over the last decade, we have increasingly observed that many blockages are more calcified (there is an excess calcium level in this blockage). Several factors are responsible for this development, including poor lifestyle, genetics, smoking, and even COVID-19. The presence of calcium deposits makes these blockages very hard, to the point where it becomes difficult to treat using conventional angioplasty techniques. Fortunately, we now have several advanced technologies that are designed specifically to break these hard calcified plaques and open up the arteries.

Broadly, these advanced technologies can be classified into two categories: balloon-based techniques and device-based techniques.

Balloon-based techniques:

• Cutting balloons have tiny micro blades around the balloons on the surface, which can be inflated to cut open the plaques.
• Scoring balloons have specialised wires that penetrate into the calcium and break it open.
• Ultra-high-pressure balloons are very strong and can be inflated at extremely high pressures to break the calcium plaques.
• Intravascular lithotripsy(IVL) is another technology that works on the same principle used to break kidney stones. It delivers shockwaves inside the artery to break down the plaque, making the blockage easier to treat.

Device-based techniques:

As far as device-based techniques are concerned, there are majorly two: Rotational atherectomy(Rotablation) and Orbital atherectomy.

• Rotational atherectomy is an age-old technique that uses a diamond-shaped burr for rotating at high-speed and drilling out calcium deposits from the artery.
• Orbital atherectomy is a more recent method that removes the calcium from the artery walls through a small crown attached to the wire that rotates in an orbital (circular) motion.

With the above-mentioned technologies, managing calcified coronary blockages has now become much safer and more effective. In addition, advanced imaging tools like intravascular imaging (OCT or IVUS) are often used during angioplasty to accurately assess the blockage and guide treatment, ensuring the best possible outcomes for patients.

(This article is authored by Dr. Pavankumar P Rasalkar, Consultant - Interventional Cardiology, Manipal Hospital Kanakapura Road.)