Device indication for calcified coronary lesions based on coronary imaging findings.

Performing percutaneous coronary intervention (PCI) for heavily calcified coronary lesions remains a significant clinical challenge. In 2023, following the availability of intravascular lithotripsy (IVL), a consensus document was published outlining imaging-guided device selection strategies for the treatment of calcified lesions. Since the publication of that document, the DUAL-PREP study has demonstrated the safety of combining rotational atherectomy (rotablator) with IVL, a strategy previously contraindicated in the original consensus. As a result, a revision of the consensus document became necessary. In the updated consensus, the fundamental principle of imaging-guided treatment planning is retained. However, a key modification is the acknowledgment that IVL may now be considered in cases where post-atherectomy imaging reveals persistent heavy calcification and further atherectomy is deemed either ineffective or potentially harmful to the patient.