Abstract Introduction Heavily calcified coronary lesions remain one of the most challenging scenarios in percutaneous coronary intervention (PCI). Intravascular lithotripsy (IVL) allows safe and effective plaque modification through acoustic shockwaves, but its indication is still mainly based on intra-procedural angiographic or intravascular imaging findings. Coronary computed tomography angiography (CCTA) provides detailed morphological assessment of calcified plaques and could serve as a non-invasive predictor of IVL need. Purpose To develop and retrospectively validate a CCTA-derived morphological score (CT-IVL score) capable of predicting the need for intravascular lithotripsy during PCI in patients with calcified coronary lesions. Methods We retrospectively analyzed patients undergoing PCI for calcified lesions between January 2024 and March 2025. Inclusion criteria were: (1) age 18 years, (2) availability of pre-procedural CCTA of diagnostic quality performed maximum 365 days before the index procedure, (3) presence of at least one calcified coronary lesion detected with CCTA treated with PCI, and (4) complete procedural and imaging data. Patients with coronary artery bypass graft as the target vessel, IVL performed for calcific in stent restenosis (ISR), or suboptimal CCTA image quality were excluded. Patients were divided into two groups according to IVL use. CCTA analysis quantified total and per-lesion calcium burden, including calcium mass, volume, density, arc, and thickness. CCTA analysis was performed with Syngo.via software. Statistical analysis was performed with SPSS. Results IVL group, n = 78; No IVL group, n = 81. Baseline characteristics were similar between groups (all p 0.05). Lesions treated with IVL exhibited significantly higher calcium burden across all CCTA parameters. Due to high collinearity among calcium indices, only calcium mass per lesion—the parameter with the lowest univariate p-value (0.004)—was included in the multivariate model. ROC analysis identified optimal cut-offs: density 960 HU, thickness 0.5 mm, and arc 225°. The CT-IVL score achieved an AUC of 0.81 (95% CI 0.74–0.87, p 0.001) in the derivation cohort and 0.85 (95% CI 0.79–0.91, p = 0.46) after 10-fold cross-validation. A threshold of CT-IVL ≥ 2 yielded sensitivity 85.7%, specificity 65.4%, PPV 70.2%, and NPV 80.8%. Conclusions The CT-IVL score, based on CCTA-derived calcium morphology, accurately predicts the need for intravascular lithotripsy during PCI. This non-invasive tool may optimize lesion selection and procedural planning, enabling a more personalized and image-guided approach to coronary interventions.Central illustration - practical useFor image description, please refer to the figure legend and surrounding text. Score performance in cross validationFor image description, please refer to the figure legend and surrounding text.
Crociani et al. (Sun,) studied this question.