Comparing Clinical Outcomes of Intravascular Lithotripsy Versus Rotational Atherectomy in Coronary Artery Calcification: A Meta‐Analysis

BACKGROUND: Coronary calcification poses a significant challenge during percutaneous coronary intervention (PCI) with intravascular lithotripsy (IVL) and rotational atherectomy (RA), which are common plaque-modifying strategies. AIMS: This meta-analysis aimed to compare the clinical and procedural outcomes of IVL and RA in patients with calcified coronary lesions. METHODS: Following PRISMA and Cochrane guidelines, PubMed, Scopus, and Web of Science were searched through January 4, 2025, for randomized and cohort studies comparing IVL and RA in patients with coronary calcification. Outcomes included mortality, myocardial infarction (MI), stroke, major adverse cardiovascular events (MACE), dissection, slow reflow, coronary perforation, stent thrombosis, revascularization, minimal stent area, lumen area gain, procedure time, and post-dilation balloon size lumen gain. Pooled estimates are reported as risk ratios (RRs) or mean differences (MDs) with 95% confidence intervals (CIs). RESULTS: Twelve studies comprising 1247 patients (612 with IVL and 635 with RA) were included. IVL was associated with a significantly lower mortality risk (RR = 0.51; 95% CI, 0.28-0.93; p = 0.03), reduced MACE (RR = 0.43; 95% CI, 0.19-0.98; p = 0.05), and lower incidence of slow reflow (RR = 0.27; 95% CI, 0.11-0.65; p = 0.004). No significant differences were found in MI, stroke, dissection, perforation, stent thrombosis, revascularization, or procedural parameters including lumen area gain and procedure time. Although post-dilation balloon size lumen gain initially favored IVL, the significance was lost after the sensitivity analysis. CONCLUSION: IVL demonstrates favorable safety and efficacy outcomes compared with RA, with lower rates of mortality, MACE, and slow reflow. These findings support the role of IVL in the treatment of calcified coronary lesions.