Evaluation of Coronary Artery Calcification Morphology on CCTA for Assessing IVL Indication

Intravascular lithotripsy (IVL) is an emerging treatment for severely calcified coronary lesions, with current appropriate use criteria primarily based on intravascular imaging such as optical coherence tomography (OCT). However, in cases where guidewire passage is challenging, coronary computed tomography angiography (CCTA) may offer a non-invasive alternative. This study investigated the feasibility of using CCTA to assess calcification morphology as a surrogate for IVL indication. A phantom study using two calcification models with known arc, thickness, and length was conducted to evaluate measurement accuracy and interobserver variability on CCTA. In addition, CCTA-based measurements were compared with OCT in 39 clinical cases involving left anterior descending artery (LAD) lesions using Pearson’s correlation and Bland–Altman analysis. In the phantom study, all measurement errors were within 10%; however, interobserver agreement was poor (ICC < 0.2). In clinical cases, CCTA demonstrated a strong correlation with OCT for calcification arc (r = 0.81), a moderate correlation for thickness (r = 0.60), and no significant correlation for length (r = 0.19), with a mean bias of + 1.44 mm. Despite limited reproducibility, CCTA provided reasonably accurate assessments of calcification arc and thickness, suggesting its potential as a supportive tool for evaluating IVL indications when intravascular imaging is not feasible. Further standardization is required, particularly in assessing calcification length.