Background: Radiation exposure in the cardiac catheterization laboratory remains a critical occupational hazard for interventional cardiologists and staff, contributing to orthopedic injuries, cataracts, and malignancy. In parallel, procedural complexity continues to increase, demanding both precision and safety. Robotic-assisted percutaneous coronary intervention (R-PCI), alongside advanced shielding systems and imaging integration, has emerged as a transformative strategy to minimize radiation and enhance operator ergonomics. Objective: This state-of-the-art review synthesizes the current clinical evidence and technological advances that support a radiation-reduction paradigm in percutaneous coronary intervention (PCI), with a particular focus on the role of R-PCI platforms, procedural modifications, and emerging shielding technologies. Methods: We reviewed published clinical trials, registries, and experimental studies evaluating robotic PCI platforms, contrast and radiation dose metrics, ergonomic implications, procedural efficiency, and radiation shielding systems. Emphasis was given to the integration of CT-based imaging (coronary computed tomography angiography—CCTA, fractional flow reserve computed tomography—FFR-CT) and low-dose acquisition protocols. Results: R-PCI demonstrated technical success rates of 81–100% and clinical success rates up to 100% in both standard and complex lesions, with significant reductions in operator radiation exposure (up to 95%) and procedural ergonomic burden. Advanced shielding technologies offer radiation dose reductions ranging from 86% to nearly 100%, while integration of (CCTA), (FFR-CT), and Artificial Intelligence (AI) -assisted procedural mapping facilitates further fluoroscopy minimization. Robotic workflows, however, remain limited by lack of device compatibility, absence of haptic feedback, and incomplete integration of physiology and imaging tools. Conclusions: R-PCI, in combination with shielding technologies and imaging integration, marks a shift towards safer, radiation-minimizing interventional strategies. This transition reflects not only a technical evolution but a philosophical redefinition of safety, precision, and sustainability in modern interventional cardiology.

Coronary artery disease (CAD) remains the leading cause of cardiovascular death in octogenarians. This group of patients represents nearly a fifth of all patients treated with percutaneous coronary intervention (PCI) in real-world practice. Octogenarians have multiple risk factors for CAD and often greater myocardial ischemia than younger counterparts, with a potential of an increased benefit from myocardial revascularization. Despite this, octogenarians are routinely under-treated and belittled in clinical trials. Age does make a difference to PCI outcomes in older people, but it is never the sole arbiter of any clinical decision, whether in relation to the heart or any other aspect of health. The decision when to perform revascularization in elderly patients and especially in octogenarians is complex and should consider the patient on an individual basis, with clarification of the goals of the therapy and the relative risks and benefits of performing the procedure. In ST-segment elevation myocardial infarction (MI), there is no upper age limit regarding urgent reperfusion and primary PCI must be the standard of care. In non-ST-segment elevation acute coronary syndromes, a strict conservative strategy must be avoided; whereas the use of a routine invasive strategy may reduce the occurrence of MI and need for revascularization at follow-up, with no established benefit in terms of mortality. In stable CAD patients, invasive therapy on top of the optimal medical therapy seems better in symptom relief and quality of life. This review summarizes the available data on percutaneous revascularization in the elderly patients and particularly in octogenarians, including practical considerations on PCI risk secondary to ageing physiology. We also analyse technical difficulties met when considering PCI in this cohort and the ongoing need for further studies to ameliorate risk stratification and eventually outcomes in these challenging patients.

Background/Objectives: Coronary artery calcification is a leading cause of stent failure and a strong predictor of adverse outcomes after percutaneous coronary intervention (PCI). Accurate characterization of calcium burden, depth, and morphology is central to procedural planning, targeted treatment, and better outcomes. This review summarizes the contemporary armamentarium for imaging calcified coronary lesions, from coronary angiography and computed tomography to advanced intracoronary imaging, and how it facilitates treatment. Methods: We synthesized evidence from landmark studies, validated imaging scoring systems, registries, and current guideline and consensus documents addressing the assessment and imaging-guided treatment of coronary calcification. Results: Invasive angiography shows poor diagnostic accuracy for coronary calcium detection, characterization, and quantification. Coronary CT angiography noninvasively quantifies calcium (Agatston score and three-dimensional volume) and supports preprocedural planning, although it may overestimate calcium volume. Intravascular imaging by means of intravascular ultrasound (IVUS) and optical coherence tomography (OCT) effectively detects coronary calcium. Their use is associated with improved clinical outcomes compared with sole angiographic guidance. The addition of near-infrared spectroscopy (NIRS-IVUS) characterizes lipids within calcified plaque and high-risk calcified nodules. OCT provides the highest spatial resolution and uniquely measures calcium thickness and longitudinal calcium length, while the utilization of artificial intelligence further enhances calcium assessment. Integration of these modalities into a morphology-based, imaging-guided approach facilitates calcium detection and modification and supports PCI optimization. Conclusions: Intravascular imaging, along with coronary CT angiography, has transformed the assessment of calcified coronary lesions. Combining their strengths enables precise, lesion-specific preparation; randomized trials show that intravascular imaging guidance improves outcomes in complex PCI, while CT-guided PCI planning is emerging as a complementary strategy whose clinical value is now being tested in randomized trials.

DOI: 10.33963/KP.15554, Published online: August 13, 2020, Authors: George Kassimis, Konstantinos C Theodoropoulos, Nestoras Kontogiannis, Tushar Raina

DOI: 10.33963/KP.15769, Published online: January 25, 2021, Authors: George Kassimis, Konstantinos C. Theodoropoulos, Nestoras Kontogiannis, Tushar Raina