From single debulking techniques to combined approaches: a review of bailout strategies in heavily calcified coronary lesions

The increase in the average age of the population leads to an inevitable increase in demand for coronary intervention in elderly patients with more comorbidities, often carriers of coronary calcifications. Calcific lesions present a major challenge in Percutaneous Coronary Interventions, often requiring debulking techniques for successful lesion preparation. In some cases, the combined use of “dedicated” devices is essential. Some imaging-based algorithms have been established to guide the stepwise treatment of severe angiographic calcification by evaluating the calcium burden in terms of its circumferential extension, length, and thickness. Mild angiographic calcifications do not require an atherectomy strategy. Moderate and severe angiographic calcifications generally require debulking techniques. Currently, practice guidelines recommend the use of rotational atherectomy to prepare heavily calcified lesions that cannot be crossed using a balloon or adequately dilated before planned stenting (bailout situations). However, the evaluation of the plaques, as well as the characteristics of the patient, should be considered when choosing the most appropriate debulking system, and sometimes a combination of different techniques may be necessary. Therefore, understanding the various debulking systems and the possible combinations of these can be crucial for optimizing the procedural outcome.