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© Author(s) (or their employer(s)) 2021. No commercial reuse. See rights and permissions. Published by BMJ. INTRODUCTION Management of patients with calcified coronary lesions represents one of the last unmet clinical needs in interventional cardiology. The age of patients referred for invasive coronary angiography with indication to revascularisation is steadily increasing. This leads to a higher proportion of patients with complex coronary artery disease (CAD) and with heavily calcified coronary stenosis. Beyond the mere epidemiological finding, the presence of calcified coronary stenosis has a significant clinical impact. In fact, the presence of moderatetosevere calcification portends to increased cardiovascular mortality and major adverse cardiovascular events in patients treated with percutaneous revascularisation. 4 Severe coronary calcification is an independent predictor of 1year stent thrombosis and target lesion revascularisation. An increased cardiovascular mortality has been reported also for patients with heavily calcified coronary stenosis treated with surgical revascularisation as compared with patients without calcified coronary arteries. This can be partly explained by the fact that complete revascularisation is seldom achieved in patients with heavily calcified coronary arteries, given the additional challenge in performing the distal anastomosis of the graft to the target coronary artery. Advanced age, the possible association of porcelain aorta and the frequent presence of comorbidities are additional factors considered within the heart team when selecting percutaneous coronary intervention (PCI) as the revascularisation option in these patients. This article, mainly directed to trainees and general cardiologists, focuses on the management of patients with heavily calcified coronary stenoses undergoing PCIs.