Calcium modifying dedicated balloons: a contemporary review

Background: Calcified coronary lesions are a major challenge in percutaneous coronary intervention (PCI), frequently leading to stent underexpansion, restenosis, and adverse events. While multiple technologies exist for plaque modification, there remains a critical need for clear guidance on the optimal selection and use of dedicated balloon-based devices. Summary: This review summarizes current evidence on scoring balloons, cutting balloons, and ultra-high-pressure (OPN NC) balloons and aims to define their specific role and indications in the treatment of calcified coronary disease. Particular attention is given to how lesion morphology, calcium characteristics, and procedural context influence device selection. Scoring balloons use external nitinol elements to create controlled focal stress, particularly effective in eccentric calcium. Cutting balloons incorporate microblades mounted on the balloon surface, allowing intimal incisions and fracture of concentric and mixed calcification or fibrotic tissue; repeated sequential inflations, as proposed in the RODIN-CUT technique, may enhance calcium disruption in a dose-dependent manner. OPN NC balloons, capable of inflations up to 35-40 atm, provide an effective last-resort option in undilatable lesions. Across devices, intravascular imaging plays a pivotal role in characterizing calcium morphology, guiding device selection and sizing, and confirming plaque modification. Conclusions: Calcium-modifying balloons provide predictable and versatile strategies for treating calcified coronary disease suitable both as a first-line option and as a complementary tool alongside intravascular lithotripsy or atherectomy. Device performance is tightly linked to lesion selection, procedural technique, and intravascular imaging guidance. An individualized, integrated, and morphology-tailored multimodality approach remains the most pragmatic strategy.