The management of spontaneous coronary artery dissection (SCAD) is lacking randomized data. This also holds for SCAD with ST-segment elevation myocardial infarction where stenting has been used to restore coronary flow. This approach can be associated with many drawbacks. Therefore, we present an alternative approach to stenting when coronary flow cannot be restored using cutting balloons alone.

Since the publication of the 2015 EAPCI consensus on rotational atherectomy, the number of percutaneous coronary interventions (PCI) performed in patients with severely calcified coronary artery disease has grown substantially. This has been prompted on one side by the clinical demand for the continuous increase in life expectancy, the sustained expansion of the primary PCI networks worldwide, and the routine performance of revascularization procedures in elderly patients; on the other side, the availability of new and dedicated technologies such as orbital atherectomy and intravascular lithotripsy, as well as the optimization of the rotational atherectomy system, has increased operators\' confidence in attempting more challenging PCI. This current EAPCI clinical consensus statement prepared in collaboration with the EURO4C-PCR group describes the comprehensive management of patients with heavily calcified coronary stenoses, starting with how to use non-invasive and invasive imaging to assess calcium burden and inform procedural planning. Objective and practical guidance is provided on the selection of the optimal interventional tool and technique based on the specific calcium morphology and anatomic location. Finally, the specific clinical implications of treating these patients are considered, including the prevention and management of complications and the importance of adequate training and education.

BACKGROUND: Percutaneous transcatheter balloon angioplasty has evolved to the current mainstay treatment for salvage of dysfunctional dialysis access. Nonetheless, it is frequently associated with recurrent vessel restenosis and the need for multiple repeat treatments in order to maintain hemodynamic patency. Cutting-balloons, covered stents or stent-grafts, and paclitaxel-coated balloons have been extensively tested and investigated with the aim to improve immediate anatomical and long-term clinical results. Areas covered: In the present overview, we discuss the background and appraise relevant medical literature on the aforementioned technologies and provide a more in-depth synthesis of the results of different clinical studies for each device category. We will also discuss the limitations in the mode of action of each group of devices and envision what the future holds for the challenging field of dialysis access interventions. Expert commentary: We propose a good practice algorithm for the treatment of thrombosed or dysfunctional dialysis access.

UNASSIGNED: Despite significant advances in treatment of coronary artery disease and improvements in interventional devices and techniques, the subset of obstructive calcified coronary artery disease remains challenging to treat. Percutaneous treatment of these lesions results in increased rates of procedural complications, as well as a higher risk of stent underexpansion and malapposition. This is associated with higher rates of restenosis, target lesion revascularization (TLR), and major adverse cardiac events (MACE). Several interventional strategies and technologies have been developed to improve lesion preparation and successful stent implantation. This includes use of cutting and scoring balloons and atherectomy devices. Several intravascular imaging techniques have also shown to have value in the treatment of complex calcified coronary lesions. These advances have improved the treatment of patients with calcified coronary disease who are often difficult to treat and frequently excluded from large randomized trials. Thoughtful, and not routine, use of rotational atherectomy can be helpful in pre-treating severely calcified lesions to achieve successful stent delivery. Orbital atherectomy represents a newer advancement in the atherectomy approach that may be beneficial in the treatment of calcified coronary disease, but further trials are needed to support its routine use.