Coronary atherectomy versus balloon angioplasty before drug-eluting stent implantation in severely calcified lesions: A systematic review and meta-analysis

Background Severe coronary calcification can impede stent delivery and affect long-term outcomes. Few trials have compared coronary atherectomy with balloon-first strategies for lesion preparation before drug-eluting stent (DES) implantation. Methods We searched MEDLINE, Embase, and the Cochrane Library through October 2025 for randomized controlled trials (RCTs) comparing coronary atherectomy with balloon angioplasty for lesion preparation before DES implantation in severely calcified coronary lesions. Results Across three RCTs, there was no significant difference in major adverse cardiovascular events between atherectomy and balloon angioplasty (risk ratio [RR] 1.05, 95% confidence interval [CI] 0.85–1.30; I 2 = 0%). Strategy success trended higher with atherectomy but did not reach statistical significance (RR 1.10, 95% CI 0.99–1.23; I 2 = 84%). No significant differences were observed for myocardial infarction (RR 1.06, 95% CI 0.80–1.42; I 2 = 0%), any revascularization (RR 0.68, 95% CI 0.25–1.82; I 2 = 83%), target lesion revascularization (RR 0.88, 95% CI 0.57–1.37; I 2 = 83%), target vessel revascularization (RR 0.89, 95% CI 0.64–1.24; I 2 = 0%), stent thrombosis (RR 2.75, 95% CI 0.94–8.06; I 2 = 0%), cardiac mortality (RR 1.49, 95% CI 0.93–2.40; I 2 = 0%), all-cause mortality (RR 1.10, 95% CI 0.79–1.54; I 2 = 0%), or procedural complications (RR 0.95, 95% CI 0.69–1.30; I 2 = 3%). Conclusions Our meta-analysis showed that routine atherectomy was comparable with balloon angioplasty in severely calcified coronary lesions. These findings support a selective, imaging-guided balloon-first strategy, reserving atherectomy for lesions that remain undilatable or uncrossable. Randomized studies of imaging-guided algorithms and emerging technologies are needed to define optimal lesion-specific strategies.