Vulnerable or high-risk coronary plaques are usually referred to as angiographically mild to moderate lesions characterized by a large plaque burden, positive vessel remodeling, thin fibrous cap, and large necrotic/lipid core. According to several pathology studies, these plaques represent the substrate of coronary thrombosis in about two-thirds of cases; therefore, there has been increasing interest in detecting and treating vulnerable plaques (VPs). Nowadays, VP detection is possible through noninvasive and invasive imaging techniques, such as coronary computed tomography, magnetic resonance imaging, intravascular ultrasound, optical coherence tomography, and near-infrared spectroscopy. Since VPs were shown to be associated with cardiovascular events in observational studies, pharmacological and non-pharmacological strategies have been investigated to achieve a regression and/or a passivation of these plaques. In addition to pharmacological therapies, mainly focused on lipid-lowering agents, there has been a recent growing interest in interventional therapies, including coronary scaffolds, stents, and drug-coated balloons. This led to the concept of preventive percutaneous coronary intervention, which, unlike the treatment of culprit lesions in acute coronary syndromes or of ischemia-inducing stenoses, as recommended by guidelines, implies the treatment of angiographically and functionally non-significant lesions based on one or more high-risk plaque characteristics as identified by noninvasive or intracoronary imaging. This article provides an updated review of key concepts in defining and detecting VPs; their prognostic value and available pharmacological and interventional management evidence will also be discussed.

Interventional cardiologists have recently become increasingly entrusted with the treatment of frail patients with complex coronary anatomy. Additionally, calcified lesions (CLs) have become more common due to the continued increase in the older population worldwide, increasing the need for simpler treatment options for such complex lesions. Hence, numerous debulking tools have recently been developed to overcome the difficulties associated with the angioplasty of CLs and to optimize stent positioning and delivery. In addition, bifurcation lesions (BLs) have always been more challenging than other lesions, requiring more specialized tools and complex strategies. Finally, intravascular imaging (IVI) is becoming increasingly important in assessing the complexity of lesions and optimizing procedural approaches. This article provides an overview of how complex procedures should be approached, from the choice of access and catheter to the use of specialized devices developed to assist cardiac catheterization laboratory operators in these complex scenarios.

Background: a wider left main bifurcation angle (LMBA) has been linked to severe plaque development in the proximal left anterior descending artery (LAD). This study aimed to identify predictors of severe proximal LAD stenosis and major adverse cardiovascular events (MACE) using coronary computed tomography angiography (CCTA). Methods: from an initial cohort of 650 consecutive patients, we analyzed 499 patients who met the inclusion criteria after exclusions. Plaque morphology and characteristics were assessed by CCTA, and MACE occurrences were recorded at follow-up. A predictive score for LAD disease progression (CLAP score) was developed and validated. Results: severe proximal LAD stenosis was detected in 32% (160/499) of patients by CCTA. MACE occurred in 12.5% of patients at follow-up. Significant predictors of MACE were LMBA > 80° (HR: 4.47; 95% CI: 3.80–6.70; p < 0.001), diabetes (HR: 2.94; 95% CI: 1.54–4.63; p = 0.031), chronic kidney disease (HR: 1.71; 95% CI: 1.31–6.72; p = 0.041), high-risk plaques (HR: 2.30; 95% CI: 1.45–3.64; p < 0.01), obstructive CAD (HR: 2.50; 95% CI: 1.50 to 4.10, p = 0.01), and calcium score (CAC) (HR: 1.05; 95% CI: 1.02–1.08, p = 0.004). The CLAP score demonstrated good discriminatory power in both the development (AUC 0.91; 95% CI: 0.86–0.96) and validation cohorts (AUC 0.85; 95% CI: 0.79–0.91); Conclusions: LMBA > 80°, diabetes, chronic kidney disease, obstructive CAD, CAC score >180 and high-risk plaques were significant predictors of MACE in CCTA patients. The CLAP score effectively predicted LAD disease progression, aiding in risk stratification and optimization of intervention strategies for suspected coronary artery disease.