What is Calcified Lesions

In coronary artery disease, calcified coronary lesions are often observed, especially in those with comorbidities and an increase in age. It presents as a circular, resistant, non-distensible vessel and therefore, is difficult to dilate by conventional angioplasty technique. High-pressure dilatation, scoring/cutting balloons and rotational atherectomy (RA) devices are highly recommended before stent implantation. The severity of calcification significantly affects survival, myocardial infarction rates, and the success of target lesion revascularization. The symptoms and causes are similar to coronary artery disease.

Risk factors

Risk factors associated with calcification:

  • Diabetes mellitus
  • Dyslipidemia
  • Hypertension
  • Smoking
  • Renal disease
  • Hyperphosphatemia
  • Parathyroid hormone abnormalities


Computed tomography coronary angiography

The key noninvasive technique for the identification of calcified lesions is computed tomography coronary angiography (CTCA). Coronary artery calcium scoring (CACS) is commonly used to measure coronary artery calcium (CAC) in CTCA. Research is suggestive of CAC having a favourable association with ECG and atherosclerosis. Most importantly, in reclassifying people with an intermediate risk of CAD (coronary artery disease), CACS plays an important role. The CACS calculation is important as most cardiovascular events occur in people with intermediate-risk, and intervention is best known for high-risk individuals to minimize risk than for those with intermediate-risk.


There are various strategies like balloon angioplasty, cutting balloon, rotational atherectomy, stenting, and laser for the treatment of coronary calcified lesions. However, it can get complicated due to vessel dissection, perforation, and vessel occlusion.

Balloon Angioplasty

Balloon-based techniques do not extract calcium, but seek to increase the elasticity of the plaque and enable stent expansion in one or several areas by cracking calcified zones. Standard calcified lesion balloon dilatation also results in non-uniform balloon expansion and consequent overexpansion of more compliant vessel segments and injury to them. The newer non-compliant OPN balloon allows uniform expansion up to 40 atm of super-high pressures.

Rotational Atherectomy

A diamond-coated elliptical burr is used in rotational atherectomy (RA) to rotate concentrically when progressing in a forward direction. Differential cutting enables the non-elastic, fibrocalcific plaque to be mechanically ablated while sparing adjacent compliant elastic vessel tissue. Calcium eccentricity, luminal region, burr scale, and degree of guidewire bias depend on the effect of RA on severely calcified lesions.

Intravascular Lithotripsy

Intravascular lithotripsy (IVL) system is a novel balloon catheter-based device that utilizes pulsatile mechanical energy for disrupting calcified lesions. Miniature emitters turn electrical energy into transient acoustic circumferential pressure, which pulses along the length of a semi-compliant balloon that disrupts both superficial and deep calcium within the vascular plaque. Usually, the balloon is sized 1:1 to the diameter of the reference vessel, and inflated with subnormal pressures to allow contact with the vessel wall while reducing static barotrauma. IVL changes calcium, both circumferentially and transmurally, in a particular way and has a preferential impact on deep calcium, relative to other techniques of ablation.

Cutting and Scoring Balloons

Cutting and scoring balloons do not remove calcium in the coronary artery. However, they enhance vessel enforcement by making distinct incisions in the atherosclerotic plaque, allowing greater lesion expansion and reducing recoil while preventing uncontrolled dissections. In lesions with mild to moderate CAC, the cutting and scoring balloon scan should be done. The sign for the cutting balloon is that the lesion is relatively short.

Coronary artery bypass graft surgery

In patients with Class III to IV CAC based on intravascular ultrasound, coronary artery bypass (CABG)/open heart surgery is recommended, as is the expected difficulty in performing PCI, including the following characteristics:

Intravascular Ultrasound

The most accurate diagnostic technique for detecting coronary calcium with high tissue penetration is intravascular ultrasound (IVUS). IVUS, however, shows the calcified arc without determining its thickness due to acoustic shadowing. Despite more limited depth penetration, optical coherence tomography, with the higher spatial resolution, offers more accurate quantification of calcific plaque such as calcium area, thickness, length and 3D volume. This provides a better predictive response to the balloon dilatation.

Optical Coherence Tomography

To recognize CAC, optical coherence tomography (OCT) has high sensitivity and specificity. In addition, because light penetrates through calcium, optical coherence tomography can be used to measure the thickness and volume of calcification.

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Frequently Asked Questions

1. What is a calcified coronary lesion?

Coronary artery calcification is calcium buildup within the walls of the arteries that supply oxygen-rich blood to the heart. This calcium causes the walls to become more hardened, as seen with atherosclerosis and leads to reduced blood supply to the heart.

2. Is calcification the same as plaque?

Coronary calcification refers to the build-up of calcified plaque within the walls of the coronary arteries.

3. How do you get rid of calcification in the arteries?

There are various methods to treat calcified arteries, such as cutting, scoring, sculpting balloons for mild to moderate lesions and atherectomy, intravascular lithotripsy, and laser for severely calcified lesions.

4. Can vitamin D cause calcification of arteries?

Vitamin D regulates calcium blood levels and affects vascular smooth muscle cell proliferation, inflammation, and the renin-angiotensin system, all of which have cardiovascular effects and could lead to coronary calcification.


Calcified lesions https://www.jacc.org/doi/full/10.1016/j.jcmg.2017.05.012
Calcified lesions symptoms https://n.neurology.org/content/53/4/777.short