New research has found that using advanced calcific plaque modification devices (ACPMDs) significantly improves outcomes in patients undergoing percutaneous coronary intervention (PCI) for chronic total occlusions (CTOs) with severe calcification. The study, which appears in the June 9 issue of JACC Cardiovascular Interventions, found that out of the 15,329 procedures analyzed, only 26% of severely calcified cases used ACPMDs such as atherectomy or intravascular lithotripsy. However, their impact was substantial as major adverse cardiac and cerebrovascular events (MACCE), were significantly lower in the ACPMD group (2.2%) compared to those treated without the devices (4.1%). Higher technical success “Applying ACPMDs in severely calcified CTO to PCI was associated with higher technical success and lower MACCE rates,” said the paper’s authors, led by Giuseppe Vadalà, MD, from the University Hospital P. Giaccone in Palermo, Italy. “In our study, ACPMD strategies were more likely used in the presence of intraplaque crossing, which somehow reflects the recommendation not to apply ACPMD in case of extraplaque crossing.” Further findings revealed that patients treated with ACPMDs achieved a technical success rate of 97.6%, compared to just 79.1% in the non-ACPMD group. Furthermore, these patients experienced fewer coronary perforations and less residual stenosis. “The presence of severe coronary calcification within the CTO, as assessed using coronary angiography, was an independent factor associated with technical failure but not with MACCE,” noted the research team. They add that the findings support growing calls for wider adoption of ACPMDs and better preprocedural planning in complex PCI cases. Calcification impact “The present study delivers an in-depth and far-reaching analysis of the impact of severe calcification on the outcomes of contemporary CTO-PCI andabout trends of ACPMD application across Europe,” the team stated. In an accompanying editorial comment, Spyridon Kostantinis, MD, from Yale University School of Medicine in New Haven, and Emmanouil Brilakis MD, PhD, from the Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, outline a structured approach to improve outcomes in treating severely CTOs. “Calcification can hinder all stages of CTO, PCI: guidewire crossing, equipment delivery, and lesion expansion, resulting in lower success rates and higher risk of complications,” they wrote. “[The investigators’] findings can be incorporated into a stepwise approach to heavily calcified CTOs….Intravascular ultrasound should be universally used in CTO PCI, especially in heavily calcified CTOs,” they added. The commentators concluded that device selection, preprocedural planning and experienced operators were key to balancing risk and efficacy in these high-stakes interventions. Sources: Vadalà G, Mashayekhi K, Behnes M, et al. Procedural Impact of Advanced Calcific Plaque Modification Devices Within Percutaneous Revascularization of Chronic Total Occlusions. JACC Cardiovasc. Interv 2025;18:1376–1390. Kostantinis S, Brilakis ES. How to Treat Severely Calcified Coronary Chronic Total Occlusions. JACC Cardiovasc. Interv 2025;18:1391–1395. Image Credit: kieferpics – stock.adobe.com