Ostio-proximal heavily calcified plaque modification with orbital atherectomy system and cutting balloon in high-risk older adults: a case series

Background Severe coronary artery calcification complicates percutaneous coronary intervention (PCI), particularly in older adults with comorbidities unsuitable for surgical revascularization. Lesion preparation is essential for optimal stent expansion; however, calcium modification strategy depends on lesion morphology and procedural feasibility. Case summary We present a case series of four high-risk older adult patients with symptomatic, heavily calcified coronary artery disease who underwent intravascular ultrasound (IVUS)-guided PCI. All patients underwent PCI following multidisciplinary heart team discussions, taking into account age, frailty, comorbidities, anatomical complexity, and patient-specific considerations. A stepwise strategy was employed, incorporating orbital atherectomy (OA) for calcium modification, followed by adjunctive balloon angioplasty and drug-eluting stent implantation. IVUS was systematically used for lesion assessment and procedural optimization. In all cases, OA enabled effective lesion preparation with substantial luminal gain (post-stent minimal stent area range 7.0–14.3 mm 2 ) and successful restoration of TIMI grade III flow. No major procedural complications or in-hospital adverse events occurred, and all patients remained symptom-free at the six-month follow-up. Discussion This series highlights the role of OA within a structured, IVUS-guided workflow for the management of complex fibrocalcific coronary lesions in high-risk older adults. OA may be particularly beneficial in cases of long, diffuse, or nodular calcification, where uniform plaque modification and device deliverability are crucial. Careful lesion selection and intravascular imaging remain essential for optimizing procedural outcomes. Conclusion In high-risk patients unsuitable for surgical revascularization, an IVUS-guided, stepwise approach incorporating OA may facilitate effective lesion preparation and satisfactory stent expansion in complex calcified coronary disease.