1.3 The Alphabet Soup of Plaque Modification: CB, RA, OA, IVL. Real or Imagined? Will SONAR Provide Insight? Are Novel Approaches Needed?

Problem Presenter: Alex Truesdell

These proceedings summarize the educational activity of the 18th Biennial Meeting of the International Andreas Gruentzig Society held January 27 to 30, 2026, in Puerto Ayora, Santa Cruz, Ecuador.

Faculty Disclosures     Sponsors

2026 IAGS Summary Document

Statement of problem or issue

In order to use drug coated balloons (DCBs, the topic of the previous two presentations), and indeed, often to implant drug-eluting stents (or bioresorbable scaffolds) or perform any percutaneous coronary intervention (PCI) at all, the target lesion has to be ‘prepared,’ a process usually referred to as plaque modification. The two primary morphological factors driving plaque modification are diffuseness of disease and extent of coronary calcification (Figure 1).

Gaps in current knowledge

With a range of plaque modification tools available (“alphabet soup”) the questions center on: (1) evaluating the lesion, and (2) planning the optimal type and/or sequence or algorithm for modification and follow-on intervention. In other words, what is the best way to evaluate the target lesion (CCTA, IVUS, OCT, physiology) and what are the ‘best’ devices to use for plaque modification and in what sequence? These questions become even larger when one considers the entire lifecycle management of coronary artery disease over the course of decades, including both clinical events as well as costs. How does any single PCI procedure fit into this larger lifecycle? Is it possible to plan, in advance, not just a single episodic PCI but the optimal set of interventions PCI for lifetime management?

Possible solutions or future directions

Data are emerging on various direct comparisons of devices. For example, at the TCT-2025 conference last October, results of two randomized non-inferiority trials were presented. The Short-CUT trial compared pretreatment with a cutting balloon (CB) to intravascular lithotripsy (IVL) prior to DES implantation.[3] The VICTORY trial compared pretreatment with a super-high-pressure noncompliant balloon to IVL prior to DES implantation.[4] The primary outcome in both trials was determined by final stent expansion, and in both trials the results were equivalent for the comparisons (i.e. non-inferior). Also presented at TCT-2025 were the results of a randomized superiority trial, the SONAR trial, which compared treatment using rotational atherectomy (RA) with IVL.[5] Here, the primary outcome was peri-procedural myocardial injury (PPMI), based on the concept of less embolic debris with IVL. However, results showed that PPMI was equally frequent in both groups (10.8% vs 7.2%, P=.58). The search for the best device strategy will continue, although the larger search for the optimal lifecycle strategy may prove more important in the long run.

References

1. Sandoval Y, et al. Coronary Computed Tomography Angiography to Guide Percutaneous Coronary Intervention: Expert Opinion from a SCAI/SCCT Roundtable. J Soc Cardiovasc Angiogr Interv. 2025;4(6):103664. doi: 10.1016/j.jscai.2025.103664. PMID: 40630246; PMCID: PMC12230455.
2. Truesdell AG, et al. Intravascular imaging during percutaneous coronary intervention: JACC State-of-the-Art Review. J Am Coll Cardiol. 2023 Feb 14;81(6):590-605. doi: 10.1016/j.jacc.2022.11.045. Erratum in: J Am Coll Cardiol. 2023 Apr 18;81(15):1550. doi: 10.1016/j.jacc.2023.03.003. PMID: 36754518.
3. Available at: www.pcronline.com/News/Congress-coverages/TCT/2025/Short-CUT-intravascular-lithotripsy-vs.-cutting-balloon-angioplasty-in-calcified-CAD. Accessed February 24, 2026.
4. Available at: www.pcronline.com/News/Congress-coverages/TCT/2025/VICTORY-Intravascular-lithotripsy-vs.-super-high-pressure-PTCA-in-calcified-and-refractory-coronary-lesions. Accessed February 24, 2026.
5. Available at: www.tctmd.com/slide/shockwave-balloon-vs-atherectomy-rotablation-calcified-coronary-artery-lesions-primary. Accessed February 24, 2026.