The emerging role of orbital atherectomy in the management of heavily calcified lesions in percutaneous coronary intervention.

Severe coronary calcification is a challenge to optimal percutaneous coronary intervention (PCI). Adequate lesion preparation is essential to achieve appropriate stent expansion and improve long-term outcomes. Recently, orbital atherectomy (OA) has emerged as an important tool for calcium modification, offering a unique mechanism of action based on centrifugal sanding and differential cutting. This review summarizes the contemporary evidence supporting OA in heavily calcified coronary disease, compares it to other established calcium modification strategies, and highlights practical scenarios where OA offers distinctive advantages. Several calcium algorithms exist, detailing start points according to balloon crossability and stepwise escalation guided by intravascular imaging. Orbital atherectomy has recently become available across centers in Europe and the United Kingdom, providing an alternative calcium‑debulking toolkit that is of particular use in some indications, with advantages over other techniques. In this review, we look at the emerging role of OA in calcified lesions, with a critical appraisal of the data and highlighting its utility drawing examples from the published literature and our center's experience.