JIM 2020: Highly calcified arteries — Prof Francesco Prati

Prof Francesco Prati (San Giovanni Addolorata Hospital, IT) discusses the challenges of treating highly calcified lesions and his experiences with intravascular imaging.
 
Questions:
1. What challenges do calcified lesions present for an operator?
2. Why is IV imaging important and what options are available?
3. Do you have a preferred imaging modality and why?
4. When in the procedure do you use imaging?
5. Should imaging be used in all calcified artery PCIs or can angiography be relied on?
 
Filmed on location at the JIM 2020. 
Interviewer: Ashlynne Merrifield
Videographer: Dom Woodruff
 

Transcript Below :

Question 1 : What challenges do calcified lesions present for an operator?

[Prati] Calcified lesions are a true challenge for interventional cardiologists. Because we have to, kind of, get rid of the calcium and be able to crack the calcium, position a stent and keep in mind that if you deploy a stent in a highly calcified lesion and we don't open up the stent enough, then we may run into trouble. 

Question 2 : Why is IV imaging important and what options are available?

[Prati] It's very important indeed because you can see the calcium from the inside of the artery. Angiography is important but of course there are very many details that only intervascular imaging modality can provide us with. So we can see the calcium, we can quantify it and then we can choose the best weapon in order to open the artery the way we like. 

Question 3 : Do you have a preferred imaging modality and why?

[Prati] I would say that there are two main imaging modalities, IVUS and OCT. We are an OCT centre, so we tend to use OCT. In terms of calcium, I do prefer OCT because you can have a very [Inaudible] assessment of the calcium and we can measure very easily the thickness of calcium. And we can also apply a score that has been recently validated. Taking into account the length of the calcium, the thickness of the calcium and the circumferential extension of the calcific components. 

Question 4 : When in the procedure do you use imaging?

[Prati] I try to use it before intervention but I must say that sometimes if lesion is very, very calcific it is difficult to negotiate the lesion with, particularly with OCT now. So sometimes, I go in, I try to open the lesion with the device. High-pressure dilatation, laser, and Shockwave, rota, etc cetera. And then later on, once I have opened the artery, then I do a second attempt, if I could not before with imaging modality, to understand if I was able to crack the plaque and therefore, to improve the anatomy. 

Question 5 : Should imaging be used in all calcified artery PCIs or can angiography be relied on?

[Prati] No, I don't think so. I mean sometimes it is difficult to understand what is the amount of calcium. Sometimes we do an angiography and angioplasty in a lesion that does not seem that calcific but then we realise that we don't open up the artery very well and then we have to approach it with imaging modality. So we try to, we attempt to, perform IVUS and OCT guided procedure when there is a lot of calcium. Again, let me stress once more time, a very important concept, our goal is when there is calcium, is to crack the plaque and to make sure then, that when we develop a stent we obtain a large lumen which is for sure a key element that'll give us a better follow-up.