What should you think about first with highly calcified lesions?

• A. Debulking
• B. Immediate stenting
• C. Bypass surgery
• D. Medical therapy only

Answer: (A)

When a lesion is highly calcified, the first priority is to modify or remove the calcium so the vessel can be expanded adequately. Debulking with plaque-modifying techniques (like atherectomy) disrupts or sands down the calcium, increasing vessel compliance and allowing a stent to be deployed with good expansion. Without this step, even strong balloon inflation may fail to expand the stent properly, leading to malapposition, restenosis, or thrombosis. After altering the calcium, stenting can be performed more safely and effectively. Bypass surgery or medical therapy alone may be considered in other contexts, but they don’t address the mechanical obstacle posed by heavy calcification in a PCI setting.