Intravascular Lithotripsy Versus Rotational Atherectomy in the Management of Calcific Coronary Lesions: A Systematic Review and Meta-Analysis

Background and Aims: Calcific coronary lesions pose significant challenges to percutaneous coronary intervention (PCI), limiting stent delivery and expansion. Intravascular lithotripsy (IVL) and rotational atherectomy (RA) are widely used plaque modification techniques; however, comparative data on their effectiveness remain limited. We aimed to compare clinical and procedural outcomes between IVL and RA in the management of calcific coronary lesions. Methods: PubMed, Embase, Scopus, and Cochrane Library were searched through January 2025 for randomized controlled trials (RCTs) and observational studies comparing IVL with RA in calcific coronary lesions undergoing PCI. The primary outcome was major adverse cardiovascular events (MACE). Secondary outcomes included all-cause mortality, myocardial infarction (MI), stroke, repeat revascularization, procedural outcomes, and minimum stent area (MSA). Random-effect models were used for outcome analysis, and meta-regression assessed the impact of baseline characteristics. Results: A total of 14 studies (2 RCTs, 12 observational; 2056 IVL patients, 3099 RA patients) were included. IVL and RA showed a comparable risk of MACE (OR 0.81; 95% CI 0.57−1.16; p: 0.26) and similar risks of all-cause mortality, MI, stroke, and repeat revascularization. IVL was associated with a lower risk of coronary perforation (OR 0.43; 95% CI 0.32−0.57; p < 0.001) and slow or no-reflow (OR 0.34; 95% CI 0.14−0.79; p 0.02). Additionally, IVL resulted in shorter procedure duration (SMD −0.30; 95% CI −0.61−0.00; p 0.05) and fluoroscopy time (SMD −0.41; 95% CI −0.62, −0.20; p 0.004). Post-procedural MSA was similar between IVL and RA. Conclusion: IVL and RA demonstrated comparable efficacy in terms of MACE and clinical outcomes in patients with calcific coronary lesions undergoing PCI. However, IVL was associated with a lower risk of coronary perforation, slow or no-reflow phenomenon, and reduced procedure duration and fluoroscopy time, suggesting a potential procedural advantage over RA.