Intravascular Lithotripsy in Calcified Coronary Lesions: Success Predictors

Coronary artery calcification (CAC) is increasingly common in patients undergoing percutaneous coronary intervention (PCI). Intravascular lithotripsy (IVL) has been established as an effective tool for modifying calcified plaque, acting on both superficial and deep calcium within vascular walls. Generated microfractures will facilitate lesion preparation with non-compliant balloons, allowing stent placement and optimizing luminal gain.

Despite its widespread use, the factors behind its remain unclear. This study aimed to identify clinical and procedural factors associated with adequate luminal gain (LG) and angiographic success, defined as residual stenosis <30%, in patients from an international multicenter IVL registry.

Van Oort, Martijn JH, et al. analyzed retrospective data from the BENELUX-IVL registry, which included patients treated with PCI and IVL (Shockwave) at seven European centers. Coronary calcification was classified as mild, moderate, or severe using angiography, IVUS, or OCT.

The primary endpoint was treatment success, defined as residual stenosis <30% and adequate LG measured by QCA. Secondary endpoints included major adverse cardiovascular events (MACE) and procedure-related complications.

454 patients were included, mean age 73.2, 75% men. Chronic coronary syndrome was present in 56% of cases, with 22 mean SYNTAX score. The most commonly treated artery was the left anterior descending (LAD) (44%).

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Mean IVL catheter diameter was 3.5±0.5 mm, with roughly 80 pulses administered per lesion. High-pressure pre- and post-dilatation were performed in 93% and 94% of cases, respectively, and an additional plaque modification technique, mainly rotational atherectomy, was used in 16% of cases. Following IVL, 77% of patients received a stent, while 13% were treated with a drug-coated balloon. Intravascular imaging was used in 52% of cases.

QCA analysis showed a significant improvement in minimum lumen diameter (MLD) (p<0.001) and reduced percentage of residual stenosis (p<0.001), with mean luminal gain 1.9±0.9 mm. Angiographic success (residual stenosis <30%) was achieved in 90% of cases, with only 1% complications directly related to IVL.

At one-year follow-up, 13% of patients experienced MACE, primarily ischemia-driven revascularization. However, this rate was significantly lower in patients with residual stenosis <30% (HR = 0.320, 95% CI: 0.114−0.898; p = 0.030).

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Multivariate analysis identified post-IVL stent implantation (p<0.001), use of intravascular imaging (p=0.024), and the presence of chronic total occlusions (CTO) (p<0.001) as independent predictors of greater luminal gain. In contrast, bifurcation lesions were associated with lower luminal gain (p=0.027).

Regarding success predictors (residual stenosis <30%), stent implantation and the treatment of long lesions were identified as favorable factors, while aorto-ostial lesions negatively impacted outcomes. Neither inflation pressure values (p=0.599) nor number of administered pulses (p=0.412) were significantly associated with LG or residual stenosis.

Conclusions

IVL technical success, defined as residual stenosis <30%, was primarily achieved in long lesions and with stenting. Additionally, the combination of intravascular imaging and stenting was associated with greater luminal gain, optimizing procedural outcomes and reducing long-term adverse events.

Original Title: Clinical and Technical Predictors of Treatment Success After Coronary Intravascular Lithotripsy in Calcific Coronary Lesions.

Reference: van Oort, Martijn JH, et al. “Clinical and Technical Predictors of Treatment Success After Coronary Intravascular Lithotripsy in Calcific Coronary Lesions.” Catheterization and Cardiovascular Interventions (2025).