Key result
Severe coronary calcification linked to ~2.5-fold higher TVR risk despite comparable stent expansion.
Why the study?
Severe coronary artery calcification is associated with adverse events after PCI, but whether residual risk persists despite optimal stent expansion is unknown.
Does severe coronary artery calcification increase the risk of target vessel revascularization in patients undergoing IVUS-guided PCI despite achieving optimal stent expansion comparable to non-calcified lesions?
Cohort (n=709)
No
Does severe coronary artery calcification increase the risk of target vessel revascularization in patients undergoing IVUS-guided PCI despite achieving optimal stent expansion comparable to non-calcified lesions?
Hazard Ratio: 2.51 (95% CI 1.33–4.74)
Absolute Event Rate: 13.7% vs 6.2%
p-value: p=0.005
Severe coronary calcification is associated with a persistently elevated risk of repeat revascularization even when optimal stent expansion is achieved, challenging the paradigm that calcification causes adverse events solely through stent underexpansion.
Severe calcification was associated with higher revascularization risk despite optimal expansion; leaves open whether lesion modification improves outcomes beyond IVUS guidance.
Background Severe coronary artery calcification (CAC) is associated with adverse events after percutaneous coronary intervention (PCI), traditionally attributed to inadequate stent expansion. Whether severe CAC confers residual risk despite optimal acute mechanical results remains unknown. Methods This single-center retrospective study included 709 patients who underwent pre-procedural intravascular ultrasound (IVUS) before PCI. Patients were classified as no calcification ( n = 417), mild CAC (arc ≤180° or length ≤5 mm, n = 168), or severe CAC (arc >180° and length >5 mm, n = 124). The primary endpoint was clinically driven target vessel revascularization (TVR); the secondary endpoint was major adverse cardiovascular events (MACE). Post-PCI minimum stent area (MSA) and expansion index were compared across groups. Multivariable Cox regression using three prespecified adjustment models was performed. Results Over a median follow-up of 18.6 months, 57 patients (8.0%) experienced TVR and 122 (17.2%) experienced MACE. Post-PCI MSA (5.9 vs. 5.6 vs. 5.8 mm 2 ; P = 0.286) and expansion index (0.89 vs. 0.88 vs. 0.88; P = 0.485) were comparable across groups, indicating acceptable acute stent expansion in severely calcified lesions. Nevertheless, severe CAC remained independently associated with increased TVR risk in the primary analysis (adjusted hazard ratio [aHR] 2.51, 95% CI 1.33–4.74, P = 0.005), persisting after extended adjustment (aHR 2.61, P = 0.007) and after excluding rotational atherectomy (RA) cases (aHR 2.29, P = 0.018). The association between severe CAC and MACE was more modest (aHR 1.77, P = 0.014) and attenuated after extended adjustment (aHR 1.49, P = 0.119). Calcified nodules, present in 64.5% of severe CAC lesions, independently predicted TVR (aHR 3.04, P < 0.001). Mild CAC showed no significant risk elevation. Conclusion Severe CAC identifies a subgroup at persistently elevated risk for repeat revascularization despite achieving stent expansion comparable to non-calcified lesions, challenging the conventional paradigm linking calcification to adverse events solely through underexpansion.
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Xiao et al. (2026) conducted a cohort in Coronary artery disease requiring percutaneous coronary intervention (n=709). Severe coronary artery calcification vs. No coronary artery calcification was evaluated on Clinically driven target vessel revascularization (TVR) (aHR 2.51, 95% CI 1.33-4.74, p=0.005). Severe coronary artery calcification independently predicted an increased risk of target vessel revascularization (aHR 2.51) compared to no calcification, despite achieving comparable acute stent expansion.
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