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.

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.

Coronary artery calcification is common in patients undergoing percutaneous coronary intervention (PCI); it impairs device delivery and stent expansion and predicts stent failure. Balloon-based techniques (non-compliant, super high-pressure, cutting and scoring balloons, intravascular lithotripsy), rotational and orbital atherectomy, and excimer laser coronary atherectomy are now widely available. This narrative review describes the mechanism of each technique, the calcium morphology it suits on intravascular imaging, and its advantages and limitations, and synthesizes the randomized trials published between 2018 and 2026, including their longer-term follow-up. Dedicated calcium modification improves procedural success compared with balloon-only strategies in selected calcified lesions, but no trial has shown fewer deaths or myocardial infarctions; the only trial powered for a clinical endpoint comparing preparation strategies found no benefit from routine orbital atherectomy. Head-to-head comparisons were powered for imaging surrogates and mostly found the techniques non-inferior to one another. Intravascular imaging guidance is associated with larger stent areas and fewer adverse events. We also review technique-specific complications and their percutaneous management, and the evidence on performing these procedures in centers without on-site cardiac surgery. Finally, we propose a lesion-based, imaging-guided approach to technique selection and outline the trials still needed.

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 overestimates calcium volume. Intravascular imaging by means of intravascular ultrasound (IVUS) and optical coherence tomography (OCT) effectively detects coronary calcium and provides the best evidence to avoid stent failure. IVUS accurately measures deep calcium, calcium arc, and length; adding near infrared spectroscopy (NIRS IVUS) characterizes lipid 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, leading to PCI optimization and improved outcomes. Conclusions: Coronary CT angiography and intravascular imaging have transformed the assessment of calcified coronary lesions. Combining their complementary strengths enables precise, lesion specific preparation and is crucial to improve outcomes in contemporary calcified lesion PCI.