The Role of Orbital Atherectomy for Complex Coronary Calcium Modification: Has It Been Eclipsed?

Severe coronary artery calcification (CAC) is a frequent finding in patients undergoing percutaneous coronary intervention (PCI) and represents a significant procedural challenge. CAC is commonly associated with ageing and comorbidities such as diabetes, hypertension, and chronic kidney disease, and contributes to vessel rigidity, impaired device delivery, and suboptimal stent expansion. These factors increase the risk of angiographic complications, as well as major adverse cardiac events compared with non-calcified lesions, negatively impacting both immediate and long-term clinical outcomes. In cases of severe calcification, traditional balloon angioplasty is often inadequate, necessitating the use of dedicated calcium modification techniques. Devices such as rotational atherectomy (RA), orbital atherectomy (OA), excimer laser coronary atherectomy (ELCA), and intravascular lithotripsy (IVL) have been developed to address these challenges. Among these, orbital atherectomy offers a potential unique dual mechanism of action and has shown promise in enhancing lesion preparation and facilitating optimal stent deployment. This review provides an overview of the role of orbital atherectomy in the management of calcified coronary lesions, evaluates current evidence on its safety and efficacy, and discusses how it may be positioned in the future, underscoring the need for a personalised, lesion-specific approach to optimise PCI outcomes.