LAUSR

Calcified coronary artery stenoses are inherently resistant to percutaneous coronary intervention (PCI). Calcium is poorly identified by fluoroscopy alone and requires intravascular imaging with ultrasound (IVUS) or optical coherence tomography (OCT) when suspected. Adequate lesion preparation with calcium modification techniques is mandatory for maximal stent expansion to avoid “stent‐ regret” and subsequent stent thrombosis or restenosis. For decades, we had only rotational atherectomy and cutting balloon (CB) angioplasty, but the recent approval of intracoronary lithotripsy (IVL, Shockwave Medical) and super high‐pressure angioplasty balloons (OPN, Swiss Interventional Systems) have created new options for lesion modification, each with advantages and disadvantages. Meanwhile, the full potential of CB angioplasty may not have been adequately examined, as inflation to only nominal pressures has been recommended in the past out of concern for dissection and perforation. In this issue of Catheterization Cardiovascular Interventions, Mangieri et al. present the results of a multicenter randomized controlled trial comparing a new high‐pressure CB angioplasty protocol with high‐pressure noncompliant balloon (NCB) angioplasty. Their Cutting balloon to Optimize Predilatation for Stent implantation (COP) study included 100 patients with >100° of calcification under IVUS and a reference vessel diameter of 2.5–4.0 mm. The CB arm utilized the semi‐compliant Wolverine CB (Boston Scientific); for safety purposes, this was recommended to be downsized 0.5 mm from the distal reference to allow for high‐pressure inflation (18–19 atm). For the NCB arm, sizing was recommended to be 1:1 with the distal reference. The primary endpoint was the minimal stent area (MSA) at the level of the calcified segment, which was found to be higher in the per protocol analysis with CB than not (CB 8.1 ± 2mm vs. NCB 7.3 ± 2.1 mm, p = 0.035). The eccentricity index was higher with CB dilatation (0.84 ± 0.07 vs. 0.8 ± 0.08, p = 0.013) reflecting a more circular dilatation. In the CB arm, there were three device failures and two Ellis Type 1 perforations. No differences in clinical outcomes were detected in this small study. The authors are commended for expanding the use of CB technology with a new high‐pressure, undersized‐balloon protocol. Such a protocol maximizes the pressure that can be applied to resistant calcified lesions without risking oversizing and perforation. The strengths of the study include the routine use of high‐resolution