Optical Coherence Tomography–Guided Calcium Modification for a Complex Calcified Nodule With Circumferential Calcium

OBJECTIVES: The study objective was to describe an optical coherence tomography (OCT)-guided strategy for stepwise calcium modification in a large protruding calcified nodule with circumferential calcium. KEY STEPS: Rotational atherectomy was used to establish device crossability and modify superficial calcium. Serial OCT was performed to assess residual calcified nodule protrusion, circumferential calcium, lumen gain, and calcium fracture. When crossability was restored but substantial mechanical constraint persisted, the strategy was escalated to intravascular lithotripsy, followed by cutting-balloon dilation. Final OCT was used to confirm stent expansion and apposition. POTENTIAL PITFALLS: Restoration of device crossability does not necessarily indicate adequate lesion preparation, whereas excessive burr escalation may increase procedural risk. Serial OCT should be used to assess the response to each modification step and guide timely strategy escalation. TAKE-HOME MESSAGE: OCT assessment may guide precise calcium modification and prevent stent underexpansion in complex calcified lesions.