To shock or to drill: comparison of intravascular lithotripsy and rotational atherectomy - a meta-analysis

Abstract Background Coronary intravascular lithotripsy (IVL) and rotational atherectomy (RA) are potent tools for calcified plaque modification before stenting. While IVL uses pressure waves to breakup calcium, RA mechanically disrupts calcium to promote vascular compliance. It is unclear if one has superior clinical outcomes than the other for calcified coronary lesion preparation before percutaneous coronary intervention (PCI). Methods All relevant studies from PubMed and Embase were included with patients (age >18 years) undergoing PCI for calcified coronary plaque treated with either IVL or RA. All-cause mortality, target lesion revascularization (TLR), and major adverse cardiovascular events (MACE) (mortality, myocardial infarction, TLR, stroke, and in-stent thrombosis) were assessed. The pooled odds ratio (OR) for binary outcomes was computed using the Mantel-Haenszel method. Random effects model was used with 95% confidence interval (CI) for statistical significance. Heterogeneity was marked by Higgins I-squared (I2) statistic. Analysis was done on Comprehensive R Archive Network in R (CRAN-R) software. Results Three studies were included (IVL n=351, RA n=118). Compared to RA, IVL had similar all-cause mortality (OR 1.0, CI 0.3-3.0, p 0.9), TLR (OR 2.1, CI 0.26-18.2, p 0.4), and MACE (OR 2.0, CI 0.9-4.1, p 0.6). There was a trend towards favorable outcomes for RA, although statistically insignificant (figure 1). Conclusion For patients undergoing PCI for calcified coronary lesions, IVL and RA demonstrated comparable clinical outcomes including all-cause mortality. Large-scale prospective studies are needed to understand the differences in clinical outcomes.