From devices to mechanisms: Towards a structural approach to plaque preparation

Coronary artery calcification remains a major challenge in percutaneous coronary intervention, impairing device delivery, vessel expansion, and clinical outcomes. Despite the availability of multiple calcium-modifying technologies, optimal treatment strategies remain unclear, and the results according to device type are difficult to interpret, as they are influenced by numerous confounding variables. This limitation reflects a predominantly device-centered approach, where plaque preparation is viewed as a preliminary step rather than a central determinant of procedural success. We propose a shift toward a structural and mechanistic understanding of lesion treatment, in which the objective is plaque transformation rather than simple lumen enlargement. This review summarizes current calcium-modifying strategies and emphasizes the importance of procedural technique, iterative device use, and intravascular imaging for real-time assessment. We introduce an integrated framework in which plaque preparation is considered a dynamic and measurable process, guiding both device selection and therapeutic strategy. By moving from a device-based to a mechanism-based approach, this paradigm aims to improve procedural coherence and better balance efficacy and safety in complex percutaneous coronary intervention.