Practice, Access, and Drivers of Decision-Making in Coronary Calcium Modification: An International Survey

Background Severe coronary artery calcification limits stent expansion and worsens percutaneous coronary intervention outcomes. The range of calcium-modification techniques has expanded, and expert algorithms have been proposed, but how operators choose between techniques, and how access, cost, and beliefs shape those choices, is not well described. Methods We conducted an international, cross-sectional, web-based survey of interventional cardiologists, assessing device and imaging availability, perceived device value, and treatment strategy through 2 clinical case vignettes comparing current and ideal practice, and opinions on treatment algorithms. Real-world vs ideal responses were compared using the McNemar test. Results Among 156 cardiologists from 30 countries (92% attendings), rotational atherectomy (94%) and intravascular lithotripsy (90%) were the most available and highest-valued devices and were most often considered part of the minimum mandatory device set (96% and 84%). Although 68% considered intravascular imaging always or usually necessary for calcified lesions, only 28% used it in >75% of cases. Decisions were operator-dependent in 63% of centers. Real-world and ideal practice differed significantly for intravascular imaging use after lesion crossing (80% vs 92%, P < .001), upfront mechanical circulatory support in cardiogenic shock (31% vs 50%, P < .001), and Impella selection (54% vs 83%, P < .001). In each comparison, operators who responded differently predominantly moved toward greater resource use when unconstrained. Conclusions Rotational atherectomy and intravascular lithotripsy are the most widely adopted technologies for calcium modification. These gaps persisted even in this predominantly well-resourced sample, suggesting that operator behavior and structural factors, as well as limited access, shape treatment decisions. Resource-stratified guidance may still help less-resourced settings.