Enhanced efficacy of rotational atherectomy in calcified nodule cases with circumferential and contralateral calcification: insights from a multicenter intravascular ultrasound imaging study

Abstract Background Calcified nodules (CN) represent a distinct manifestation of coronary atherosclerosis, characterized by irregular, protruding calcific deposits that disrupt the vessel lumen. CN has been implicated in restenosis following percutaneous coronary intervention (PCI). Rotational atherectomy (RA) is a promising debulking device for severely calcified lesions and is frequently employed for CN, while there are few reports on its effectiveness. Purpose To evaluate the association between RA use and target lesion revascularization (TLR) rate, and to explore intravascular ultrasound (IVUS)-defined calcification characteristics in which RA is effective. Methods This multicenter study analyzed 206 patients with de novo CN who underwent PCI with IVUS guidance. IVUS imaging was used to assess the presence of circumferential calcification within the lesion adjacent to CN. Based on quadrant analysis, a calcified lesion observed in cross-sectional imaging at the minimum lumen area was classified as contralateral if it was located in quadrants 2 or 3 relative to the CN. This was referred to as contralateral calcification (Figure 1). Predictors of TLR were analyzed using a multivariate Cox proportional hazards model, followed by a subgroup analysis to evaluate the effect of RA. Results Among the 206 cases, 78 (38%) underwent PCI with RA. Although there were no significant differences in clinical backgrounds or drug-eluting stent usage between groups, the proportion of ACS cases was significantly lower in the RA group than in the non-RA group (p0.001). Additionally, the RA group had significantly more cases with calcified lesions contralateral to CN (p 0.001) (Table). During a median follow-up of 2.8 years (interquartile range: 2.4 to 3.2 years), TLR occurred in 63 patients (30.6%). In univariate Cox proportional hazard analysis, RA use was significantly associated with a lower risk of TLR (hazard ratio HR: 0.56, 95% confidence interval CI 0.32-0.96, P=0.035). In multivariate analysis, RA use (HR: 0.53, 95% CI 0.29-0.98, P=0.04) and adjacent circumferential calcification (HR: 4.20, 95% CI 2.37-7.45, P0.001) were identified as significant predictors of TLR. Subgroup analysis demonstrated that patients with adjacent circumferential calcification or contralateral calcification had better outcomes when treated with RA (Figure 2). Furthermore, contralateral calcification significantly interacted with the impact of RA use on TLR (interaction P=0.002). Conclusions The use of RA was significantly associated with a reduction in TLR incidence, whereas circumferential calcification within the adjacent lesion of CN was related to an increased risk of TLR. Our findings underscore that in cases with calcified lesions contralateral to the CN, the use of RA may effectively reduce restenosis rates.Table and Figure 1