Interventional Cardiology has undergone many changes and has become a broad subspecialty. Lesion preparation of calcified stenoses poses a challenge for practitioners. The main risk factors for coronary calcifications are age, male gender, obesity, hypertension, hypercholesteremia, diabetes and smoking. With ageing societies and inclining numbers of risk factors, the ongoing increase in the incidence of coronary calcifications will continue to rise. Current developments in imaging techniques can aid in assessing calcified lesions, allowing a multitude of implications: application of artificial intelligence, IVUS, OCT and FFR methods can be expected to yield information on coronary calcification phenotypes, their incidence, connection to aetiology and enhance knowledge on risk factors. More objective evidence regarding calcium modification techniques and materials used will be accessible. Quality of care and provider training can be improved. A multitude of methods and tools to modify coronary calcifications has been developed in the last decades: non-compliant balloons, super-high-pressure balloons, specialty balloons (cutting, scoring), rotational atherectomy, orbital atherectomy, excimer laser atherectomy and intravascular lithotripsy represent the latest options in the interventional cardiologist’s armory. However, evidence, especially of comparative type, is sparse and divided into many componential studies, only allowing confined advice on the superiority of one solution. Practitioner expertise mostly relies on experience and good judgement over the last few years. However, intensified appeals for independent and comparative research have emerged lately, and current developments have led to consensus papers with more concise rules regarding intravascular imaging and consequential decisions on calcium modification technique to be used.