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Current Cardiology Reviews

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ISSN (Print): 1573-403X
ISSN (Online): 1875-6557

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Review Article

Calcium Modification Therapies in Contemporary Percutaneous Coronary Intervention

Author(s): Mohammad Zaidan*, Mohammad Alkhalil and Khaldoon Alaswad

Volume 18, Issue 1, 2022

Published on: 28 January, 2022

Article ID: e281221199533 Pages: 10

DOI: 10.2174/1573403X18666211228095457

Price: $65

Abstract

Coronary Artery Calcification (CAC) has been known to be associated with worse Percutaneous Coronary Intervention (PCI) short- and long-term outcomes. Nowadays, with the increased prevalence of the risk factors leading to CAC in the population and also more PCI procedures done in older patients and with the growing number of higher-risk cases of Chronic Total Occlusion (CTO) PCI and PCI after Coronary Artery Bypass Grafting (CABG), severe cases of CAC are now encountered on a daily basis in the catheterization lab and remain a big challenge to the interventional community, making it crucial to identify cases of severe CAC and plan a CAC PCI modification strategy upfront. Improved CAC detection with intravascular imaging helped identify more of these severe CAC cases and predict response to therapy and stent expansion based on CAC distribution in the vessel. Multiple available therapies for CAC modification have evolved over the years. Familiarity with the specifics and special considerations and limitations of each of these tools are essential in the choice and application of these therapies when used in severe CAC treatment. In this review, we discuss CAC pathophysiology, modes of detection, and different available therapies for CAC modification.

Keywords: Calcification, atherectomy, intervascular lithotripsy, optical coherence tomography, intravascular ultrasound, stent, percutaneous intervention, orbital atherectomy, rotational atherectomy.

Graphical Abstract

[1]
Vliegenthart R, Oudkerk M, Hofman A, et al. Coronary calcification improves cardiovascular risk prediction in the elderly. Circulation 2005; 112(4): 572-7.
[http://dx.doi.org/10.1161/CIRCULATIONAHA.104.488916]
[2]
Bourantas CV, Zhang YJ, Garg S, et al. Prognostic implications of severe coronary calcification in patients undergoing coronary artery bypass surgery: An analysis of the SYNTAX study. Catheter Cardiovasc Interv 2015; 85(2): 199-206.
[http://dx.doi.org/10.1002/ccd.25545] [PMID: 24824456]
[3]
Wang L, Jerosch-Herold M, Jacobs DR Jr, Shahar E, Detrano R, Folsom AR. Coronary artery calcification and myocardial perfusion in asymptomatic adults: The MESA (Multi-ethnic study of atherosclerosis). J Am Coll Cardiol 2006; 48(5): 1018-26.
[http://dx.doi.org/10.1016/j.jacc.2006.04.089] [PMID: 16949496]
[4]
Kalra SS, Shanahan CM. Vascular calcification and hypertension: Cause and effect. Ann Med 2012; 44(Suppl. 1): S85-92.
[http://dx.doi.org/10.3109/07853890.2012.660498] [PMID: 22713153]
[5]
Généreux P, Madhavan MV, Mintz GS, et al. Ischemic outcomes after coronary intervention of calcified vessels in acute coronary syndromes. Pooled analysis from the HORIZONS-AMI (harmonizing outcomes with revascularization and stents in acute myocardial infarction) and ACUITY (acute catheterization and urgent intervention triage strategy) TRIALS. J Am Coll Cardiol 2014; 63(18): 1845-54.
[http://dx.doi.org/10.1016/j.jacc.2014.01.034] [PMID: 24561145]
[6]
Demer LL, Tintut Y. Vascular calcification: Pathobiology of a multifaceted disease. Circulation 2008; 117(22): 2938-48.
[http://dx.doi.org/10.1161/CIRCULATIONAHA.107.743161] [PMID: 18519861]
[7]
Abedin M, Tintut Y, Demer LL. Vascular calcification: Mechanisms and clinical ramifications. Arterioscler Thromb Vasc Biol 2004; 24(7): 1161-70.
[http://dx.doi.org/10.1161/01.ATV.0000133194.94939.42] [PMID: 15155384]
[8]
Johnson RC, Leopold JA, Loscalzo J. Vascular calcification: Pathobiological mechanisms and clinical implications. Circ Res 2006; 99(10): 1044-59.
[http://dx.doi.org/10.1161/01.RES.0000249379.55535.21] [PMID: 17095733]
[9]
van Setten J, Isgum I, Smolonska J, et al. Genome-wide association study of coronary and aortic calcification implicates risk loci for coronary artery disease and myocardial infarction. Atherosclerosis 2013; 228(2): 400-5.
[http://dx.doi.org/10.1016/j.atherosclerosis.2013.02.039] [PMID: 23561647]
[10]
Hofmann Bowman MA, McNally EM. Genetic pathways of vascular calcification. Trends Cardiovasc Med 2012; 22(4): 93-8.
[http://dx.doi.org/10.1016/j.tcm.2012.07.002] [PMID: 23040839]
[11]
O’Donnell CJ, Kavousi M, Smith AV, et al. Genome-wide association study for coronary artery calcification with follow-up in myocardial infarction. Circulation 2011; 124(25): 2855-64.
[http://dx.doi.org/10.1161/CIRCULATIONAHA.110.974899] [PMID: 22144573]
[12]
Sangiorgi G, Rumberger JA, Severson A, et al. Arterial calcification and not lumen stenosis is highly correlated with atherosclerotic plaque burden in humans: A histologic study of 723 coronary artery segments using nondecalcifying methodology. J Am Coll Cardiol 1998; 31(1): 126-33.
[http://dx.doi.org/10.1016/S0735-1097(97)00443-9] [PMID: 9426030]
[13]
Kelly-Arnold A, Maldonado N, Laudier D, Aikawa E, Cardoso L, Weinbaum S. Revised microcalcification hypothesis for fibrous cap rupture in human coronary arteries. Proc Natl Acad Sci USA 2013; 110(26): 10741-6.
[http://dx.doi.org/10.1073/pnas.1308814110] [PMID: 23733926]
[14]
Wong ND, Kouwabunpat D, Vo AN, et al. Coronary calcium and atherosclerosis by ultrafast computed tomography in asymptomatic men and women: Relation to age and risk factors. Am Heart J 1994; 127(2): 422-30.
[http://dx.doi.org/10.1016/0002-8703(94)90133-3] [PMID: 8296711]
[15]
Yamamoto H, Imazu M, Hattori Y, et al. Predicting angiographic narrowing > or = 50% in diameter in each of the three major arteries by amounts of calcium detected by electron beam computed tomographic scanning in patients with chest pain. Am J Cardiol 1998; 81(6): 778-80.
[http://dx.doi.org/10.1016/S0002-9149(97)01011-4] [PMID: 9527093]
[16]
Greenland P, LaBree L, Azen SP, Doherty TM, Detrano RC. Coronary artery calcium score combined with Framingham score for risk prediction in asymptomatic individuals. JAMA 2004; 291(2): 210-5.
[http://dx.doi.org/10.1001/jama.291.2.210] [PMID: 14722147]
[17]
Bourantas CV, Zhang YJ, Garg S, et al. Prognostic implications of coronary calcification in patients with obstructive coronary artery disease treated by percutaneous coronary intervention: A patient-level pooled analysis of 7 contemporary stent trials. Heart 2014; 100(15): 1158-64.
[http://dx.doi.org/10.1136/heartjnl-2013-305180] [PMID: 24846971]
[18]
Mintz GS, Popma JJ, Pichard AD, et al. Patterns of calcification in coronary artery disease. A statistical analysis of intravascular ultrasound and coronary angiography in 1155 lesions. Circulation 1995; 91(7): 1959-65.
[http://dx.doi.org/10.1161/01.CIR.91.7.1959] [PMID: 7895353]
[19]
Tanenbaum SR, Kondos GT, Veselik KE, Prendergast MR, Brundage BH, Chomka EV. Detection of calcific deposits in coronary arteries by ultrafast computed tomography and correlation with angiography. Am J Cardiol 1989; 63(12): 870-2.
[http://dx.doi.org/10.1016/0002-9149(89)90060-X] [PMID: 2929446]
[20]
Joshi NV, Vesey AT, Williams MC, et al. 18F-fluoride positron emission tomography for identification of ruptured and high-risk coronary atherosclerotic plaques: A prospective clinical trial. Lancet 2014; 383(9918): 705-13.
[http://dx.doi.org/10.1016/S0140-6736(13)61754-7]
[21]
Kwiecinski J, Tzolos E, Adamson PD, et al. Coronary 18F-sodium fluoride uptake predicts outcomes in patients with coronary artery disease. J Am Coll Cardiol 2020; 75(24): 3061-74.
[http://dx.doi.org/10.1016/j.jacc.2020.04.046] [PMID: 32553260]
[22]
Puchner SB, Liu T, Mayrhofer T, et al. High-risk plaque detected on coronary CT angiography predicts acute coronary syndromes independent of significant stenosis in acute chest pain: Results from the ROMICAT-II trial. J Am Coll Cardiol 2014; 64(7): 684-92.
[http://dx.doi.org/10.1016/j.jacc.2014.05.039] [PMID: 25125300]
[23]
Topol EJ, Nissen SE. Our preoccupation with coronary luminology. The dissociation between clinical and angiographic findings in ischemic heart disease. Circulation 1995; 92(8): 2333-42.
[http://dx.doi.org/10.1161/01.CIR.92.8.2333] [PMID: 7554219]
[24]
Friedrich GJ, Moes NY, Mühlberger VA, et al. Detection of intralesional calcium by intracoronary ultrasound depends on the histologic pattern. Am Heart J 1994; 128(3): 435-41.
[http://dx.doi.org/10.1016/0002-8703(94)90614-9] [PMID: 8074002]
[25]
Kawasaki M, Bouma BE, Bressner J, et al. Diagnostic accuracy of optical coherence tomography and integrated backscatter intravascular ultrasound images for tissue characterization of human coronary plaques. J Am Coll Cardiol 2006; 48(1): 81-8.
[http://dx.doi.org/10.1016/j.jacc.2006.02.062] [PMID: 16814652]
[26]
Kwon TG, Seo YH, Lee CS, et al. Discrepancy of calcium detection between gray scale intravascular ultrasound and spectral analysis of radiofrequency data. Int J Cardiol 2013; 167(6): 2611-6.
[http://dx.doi.org/10.1016/j.ijcard.2012.06.123] [PMID: 22819606]
[27]
Kume T, Okura H, Kawamoto T, et al. Assessment of the coronary calcification by optical coherence tomography. EuroIntervention 2011; 6(6): 768-72.
[http://dx.doi.org/10.4244/EIJV6I6A130] [PMID: 21205603]
[28]
Fujino A, Mintz GS, Lee T, et al. Predictors of calcium fracture derived from balloon angioplasty and its effect on stent expansion assessed by optical coherence tomography. JACC Cardiovasc Interv 2018; 11(10): 1015-7.
[http://dx.doi.org/10.1016/j.jcin.2018.02.004] [PMID: 29798768]
[29]
Kini AS, Vengrenyuk Y, Pena J, et al. Optical coherence tomography assessment of the mechanistic effects of rotational and orbital atherectomy in severely calcified coronary lesions. Catheter Cardiovasc Interv 2015; 86(6): 1024-32.
[http://dx.doi.org/10.1002/ccd.26000] [PMID: 25964009]
[30]
Savage MP, Goldberg S, Hirshfeld JW, et al. Clinical and angiographic determinants of primary coronary angioplasty success. J Am Coll Cardiol 1991; 17(1): 22-8.
[http://dx.doi.org/10.1016/0735-1097(91)90700-J] [PMID: 1987229]
[31]
Tan K, Sulke N, Taub N, Sowton E. Clinical and lesion morphologic determinants of coronary angioplasty success and complications: current experience. J Am Coll Cardiol 1995; 25(4): 855-65.
[http://dx.doi.org/10.1016/0735-1097(94)00462-Y] [PMID: 7884088]
[32]
Detre KM, Holmes DR Jr, Holubkov R, et al. Incidence and consequences of periprocedural occlusion. The 1985-1986 national heart, lung, and blood institute percutaneous transluminal coronary angioplasty registry. Circulation 1990; 82(3): 739-50.
[http://dx.doi.org/10.1161/01.CIR.82.3.739] [PMID: 2394000]
[33]
Nobuyoshi M, Kimura T, Ohishi H, et al. Restenosis after percutaneous transluminal coronary angioplasty: Pathologic observations in 20 patients. J Am Coll Cardiol 1991; 17(2): 433-9.
[http://dx.doi.org/10.1016/S0735-1097(10)80111-1] [PMID: 1991900]
[34]
Abdel-Wahab M, Richardt G, Joachim Büttner H, et al. High-speed rotational atherectomy before paclitaxel-eluting stent implantation in complex calcified coronary lesions: The randomized ROTAXUS (Rotational Atherectomy Prior to taxus stent treatment for complex native Coronary Artery Disease) trial. JACC Cardiovasc Interv 2013; 6(1): 10-9.
[http://dx.doi.org/10.1016/j.jcin.2012.07.017] [PMID: 23266232]
[35]
Mosseri M, Satler LF, Pichard AD, Waksman R. Impact of vessel calcification on outcomes after coronary stenting. Cardiovasc Revasc Med 2005; 6(4): 147-53.
[http://dx.doi.org/10.1016/j.carrev.2005.08.008] [PMID: 16326375]
[36]
Barbato E, Shlofmitz E, Milkas A, Shlofmitz R, Azzalini L, Colombo A. State of the art: Evolving concepts in the treatment of heavily calcified and undilatable coronary stenoses - from debulking to plaque modification, a 40-year-long journey. EuroIntervention 2017; 13(6): 696-705.
[http://dx.doi.org/10.4244/EIJ-D-17-00473]
[37]
Okura H, Hayase M, Shimodozono S, et al. Restenosis reduction by cutting balloon evaluation. mechanisms of acute lumen gain following cutting balloon angioplasty in calcified and noncalcified lesions: An intravascular ultrasound study. Catheter Cardiovasc Interv 2002; 57(4): 429-36.
[http://dx.doi.org/10.1002/ccd.10344]
[38]
Mauri L, Bonan R, Weiner BH, et al. Cutting balloon angioplasty for the prevention of restenosis: Results of the cutting balloon global randomized trial. Am J Cardiol 2002; 90(10): 1079-83.
[http://dx.doi.org/10.1016/S0002-9149(02)02773-X]
[39]
Vaquerizo B, Serra A, Miranda F, et al. Aggressive plaque modification with rotational atherectomy and/or cutting balloon before drug-eluting stent implantation for the treatment of calcified coronary lesions. J Interv Cardiol 2010; 23(3): 240-8.
[http://dx.doi.org/10.1111/j.1540-8183.2010.00547.x] [PMID: 20636844]
[40]
de Ribamar Costa J Jr., Mintz GS, Carlier SG, et al. Nonrandomized comparison of coronary stenting under intravascular ultrasound guidance of direct stenting without predilation versus conventional predilation with a semi-compliant balloon versus predilation with a new scoring balloon. Am J Cardiol 2007; 100(5): 812-7.
[http://dx.doi.org/10.1016/j.amjcard.2007.03.100]
[41]
Abdel-Wahab M, Toelg R, Byrne RA, et al. High-speed rotational atherectomy versus modified balloons prior to drug-eluting stent implantation in severely calcified coronary lesions. Circ Cardiovasc Interv 2018; 11(10): e007415.
[http://dx.doi.org/10.1161/CIRCINTERVENTIONS.118.007415] [PMID: 30354632]
[42]
Amemiya K, Yamamoto MH, Maehara A, et al. Effect of cutting balloon after rotational atherectomy in severely calcified coronary artery lesions as assessed by optical coherence tomography. Catheter Cardiovasc Interv 2019; 94(7): 936-44.
[http://dx.doi.org/10.1002/ccd.28278] [PMID: 30977278]
[43]
Matsukawa R, Kozai T, Tokutome M, et al. Plaque modification using a cutting balloon is more effective for stenting of heavily calcified lesion than other scoring balloons. Cardiovasc Interv Ther 2019; 34(4): 325-34.
[http://dx.doi.org/10.1007/s12928-019-00578-w]
[44]
Giugliano GR, Cox N, Popma J. Cutting balloon entrapment during treatment of in-stent restenosis: An unusual complication and its management. J Invasive Cardiol 2005; 17(3): 168-70.
[PMID: 15867449]
[45]
Vemula P, Kalavakunta JK, Abela GS, Karve M. A rare and serious unforeseen complication of cutting balloon angioplasty. Case Rep Cardiol 2014; 2014: 246784.
[http://dx.doi.org/10.1155/2014/246784] [PMID: 24826307]
[46]
Secco GG, Ghione M, Mattesini A, et al. Very high-pressure dilatation for undilatable coronary lesions: Indications and results with a new dedicated balloon. EuroIntervention 2016; 12(3): 359-65.
[http://dx.doi.org/10.4244/EIJY15M06_04] [PMID: 26111405]
[47]
Zimarino M, Corcos T, Bramucci E, Tamburino C. Rotational atherectomy: A “survivor” in the drug-eluting stent era. Cardiovasc Revasc Med 2012; 13(3): 185-92.
[http://dx.doi.org/10.1016/j.carrev.2012.03.002] [PMID: 22522057]
[48]
Warth DC, Leon MB, O’Neill W, Zacca N, Polissar NL, Buchbinder M. Rotational atherectomy multicenter registry: Acute results, complications and 6-month angiographic follow-up in 709 patients. J Am Coll Cardiol 1994; 24(3): 641-8.
[http://dx.doi.org/10.1016/0735-1097(94)90009-4] [PMID: 8077533]
[49]
Whitlow PL, Bass TA, Kipperman RM, et al. Results of the study to determine rotablator and transluminal angioplasty strategy (STRATAS). Am J Cardiol 2001; 87(6): 699-705.
[http://dx.doi.org/10.1016/S0002-9149(00)01486-7]
[50]
Safian RD, Feldman T, Muller DW, et al. Coronary angioplasty and rotablator atherectomy trial (CARAT): Immediate and late results of a prospective multicenter randomized trial. Catheter Cardiovasc Interv 2001; 53(2): 213-20.
[http://dx.doi.org/10.1002/ccd.1151]
[51]
Reisman M, Shuman BJ, Dillard D, et al. Analysis of low-speed rotational atherectomy for the reduction of platelet aggregation. Cathet Cardiovasc Diagn 1998; 45(2): 208-14.
[http://dx.doi.org/10.1002/(SICI)1097-0304(199810)45:2<208::AID-CCD21>3.0.CO;2-F]
[52]
Parikh K, Chandra P, Choksi N, Khanna P, Chambers J. Safety and feasibility of orbital atherectomy for the treatment of calcified coronary lesions: The ORBIT I trial. Catheter Cardiovasc Interv 2013; 81(7): 1134-9.
[http://dx.doi.org/10.1002/ccd.24700] [PMID: 23460596]
[53]
Chambers JW, Feldman RL, Himmelstein SI, et al. Pivotal trial to evaluate the safety and efficacy of the orbital atherectomy system in treating de novo, severely calcified coronary lesions (ORBIT II). JACC Cardiovasc Interv 2014; 7(5): 510-8.
[http://dx.doi.org/10.1016/j.jcin.2014.01.158] [PMID: 24852804]
[54]
Baumbach A, Bittl JA, Fleck E, et al. Acute complications of excimer laser coronary angioplasty: A detailed analysis of multicenter results. Coinvestigators of the U.S. and European percutaneous excimer laser coronary angioplasty (PELCA) registries. J Am Coll Cardiol 1994; 23(6): 1305-13.
[http://dx.doi.org/10.1016/0735-1097(94)90371-9] [PMID: 8176087]
[55]
Bittl JA, Sanborn TA, Tcheng JE, Siegel RM, Ellis SG. Clinical success, complications and restenosis rates with excimer laser coronary angioplasty. Am J Cardiol 1992; 70(20): 1533-9.
[http://dx.doi.org/10.1016/0002-9149(92)90453-6] [PMID: 1466319]
[56]
Mintz GS, Kovach JA, Javier SP, et al. Mechanisms of lumen enlargement after excimer laser coronary angioplasty. An intravascular ultrasound study. Circulation 1995; 92(12): 3408-14.
[http://dx.doi.org/10.1161/01.CIR.92.12.3408]
[57]
Fernandez JP, Hobson AR, McKenzie D, et al. Beyond the balloon: excimer coronary laser atherectomy used alone or in combination with rotational atherectomy in the treatment of chronic total occlusions, non-crossable and non-expansible coronary lesions. EuroIntervention 2013; 9(2): 243-50.
[http://dx.doi.org/10.4244/EIJV9I2A40] [PMID: 23454891]
[58]
Lee T, Shlofmitz RA, Song L, et al. The effectiveness of excimer laser angioplasty to treat coronary in-stent restenosis with peri-stent calcium as assessed by optical coherence tomography. EuroIntervention 2019; 15(3): e279-88.2019;
[http://dx.doi.org/10.4244/EIJ-D-18-00139]
[59]
Veerasamy M, Gamal AS, Jabbar A, Ahmed JM, Egred M. Excimer laser with and without contrast for the management of under-expanded stents. J Invasive Cardiol 2017; 29(11): 364-9.
[PMID: 29086727]
[60]
Brinton TJ, Ali ZA, Hill JM, et al. Feasibility of shockwave coronary intravascular lithotripsy for the treatment of calcified coronary stenoses. Circulation 2019; 139(6): 834-6.
[http://dx.doi.org/10.1161/CIRCULATIONAHA.118.036531]
[61]
Serruys PW, Katagiri Y, Onuma Y. Shaking and breaking calcified plaque: Lithoplasty, a breakthrough in interventional armamentarium? JACC Cardiovasc Imaging 2017; 10(8): 907-11.
[http://dx.doi.org/10.1016/j.jcmg.2017.05.011] [PMID: 28797413]
[62]
Ali ZA, Brinton TJ, Hill JM, et al. Optical coherence tomography characterization of coronary lithoplasty for treatment of calcified lesions: First description. JACC Cardiovasc Imaging 2017; 10(8): 897-906.
[http://dx.doi.org/10.1016/j.jcmg.2017.05.012]
[63]
Ali ZA, Nef H, Escaned J, et al. Safety and effectiveness of coronary intravascular lithotripsy for treatment of severely calcified coronary stenoses: The disrupt CAD II study. Circ Cardiovasc Interv 2019; 12(10): e008434.
[http://dx.doi.org/10.1161/CIRCINTERVENTIONS.119.008434] [PMID: 31553205]
[64]
Hill JM, Kereiakes DJ, Shlofmitz RA, et al. Intravascular lithotripsy for treatment of severely calcified coronary artery disease. J Am Coll Cardiol 2020; 76(22): 2635-46.
[http://dx.doi.org/10.1016/j.jacc.2020.09.603] [PMID: 33069849]
[65]
McQuillan C, Alkhalil M, Johnston PW. A paced heart without a pacemaker. Eur Heart J 2019; 40(10): 819a.
[http://dx.doi.org/10.1093/eurheartj/ehy749] [PMID: 30428000]
[66]
Osswald BR, Blackstone EH, Tochtermann U, et al. Does the completeness of revascularization affect early survival after coronary artery bypass grafting in elderly patients? Eur J Cardiothorac Surg 2001; 20(1): 120-5.
[http://dx.doi.org/10.1016/S1010-7940(01)00743-6] [PMID: 11423284]
[67]
Nakayama Y, Sakata R, Ura M, Miyamoto TA. Coronary artery bypass grafting in dialysis patients. Ann Thorac Surg 1999; 68(4): 1257-61.
[http://dx.doi.org/10.1016/S0003-4975(99)00696-7] [PMID: 10543489]
[68]
Castagna MT, Mintz GS, Ohlmann P, et al. Incidence, location, magnitude, and clinical correlates of saphenous vein graft calcification: An intravascular ultrasound and angiographic study. Circulation 2005; 111(9): 1148-52.
[http://dx.doi.org/10.1161/01.CIR.0000157160.69812.55]
[69]
Hemetsberger R, Gori T, Toelg R, et al. Optical coherence tomography assessment in patients treated with rotational atherectomy versus modified balloons: PREPARE-CALC OCT. Circ Cardiovasc Interv 2021; 14(3): e009819.
[http://dx.doi.org/10.1161/CIRCINTERVENTIONS.120.009819] [PMID: 33641372]
[70]
Kubo T, Shimamura K, Ino Y, et al. Superficial calcium fracture after PCI as assessed by OCT. JACC Cardiovasc Imaging 2015; 8(10): 1228-9.
[http://dx.doi.org/10.1016/j.jcmg.2014.11.012] [PMID: 25797130]
[71]
Fujino A, Mintz GS, Matsumura M, et al. A new optical coherence tomography-based calcium scoring system to predict stent underexpansion. EuroIntervention 2018; 13(18): e2182-9.
[http://dx.doi.org/10.4244/EIJ-D-17-00962] [PMID: 29400655]

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