Arterial Deposition of Calcium and Outcomes of Peripheral Interventions: Is It Time to Redefine the "Gold

Patients with severe peripheral artery disease and critical limb ischemia frequently present with multi- level disease characterized by variable densities of calcium deposits, which are underestimated by more than 50% during angiography. These calcified lesions are associated with an increased rate of complications and poor clini - cal outcomes due to their high resistance to angioplasty (the "gold standard"), generated by the heterogeneous deposition of calcium deposits along the different layers of the arterial wall. When these heterogeneous deposits are subject to increasing barometric pressures, the distribution of the pressure vectors is unpredictable with a tendency to follow the path of least resistance, increasing the risk of dissection, plaque rupture, embolization, and no-flow. In recent years with the advent of new technologies, we have learned that by modifying the architecture of these calcium deposits, the overall vessel wall resistance to barometric pressure is lessened and the pressure vectors are more homogenously distributed, thus decreasing the likelihood of adverse outcomes. This review at- tempts to condense the most recent and relevant data that support these physiologic principles while challenging the status quo of peripheral interventions as it appears that we are witnessing a change of paradigm where plaque and vessel wall modification, in conjunction with angioplasty and possibly drug delivery, may become the new gold standard.