Severe coronary artery calcification represents a significant challenge in interventional cardiology. Rotational atherectomy (RA) has been traditionally chosen to manage this kind of lesions, despite limitations inherent to its technical complexity, procedure duration and risk of vascular injury. In this context, intravascular lithotripsy (IVL) has surged as an innovative alternative, one which allows safe stent expansion without arterial wall compromise.
11 studies were looked at (10 retrospective cohorts and one open-label clinical trial) including a total of 2,120 patients; 1,127 were treated with IVL and 993 with RA. Mean patient age was 72.1 Both groups presented frequent comorbidities: hypertension (IVL: 84.9%, RA: 100%), dyslipidemia (IVL: 96.2%, RA: 93.4%) and diabetes mellitus (IVL: 35%, RA: up to 46%), while chronic kidney disease was observed in 15 to 20% of cases.
All treated lesions presented severe calcification, confirmed by angiographic or intravascular imaging. Left main lesions represented up to 25% of procedures, and were more frequent among IVL patients. Complex bifurcations were present in 15% to 30% of cases. Most lesions were classified as type B2/C according to ACC/AHA, with mean length 21.4 mm in IVL patients and 24.1 mm in RA patients, and vessel diameters ranging between 2.5 and 3.5 mm. RA required more technical steps and more frequent use of adjunctive devices, which increased both procedure length and complexity. In contrast, IVL was easier to use, even in complex anatomies.
Procedural success, defined as lumen gain and adequate stent expansion, was the primary outcome. Secondary outcomes were mortality, contrast volume, procedure duration and associated complications.
Compared against RA, IVL showed significant advantages seeing as it reduced contrast volume, with mean difference −17.45 mL (CI 95%: −32.79 a −2.11; I² = 89%), and procedural length, with mean reduction 27.9 minutes (CI 95%: −30.11 a −25.68; I² = 92.3%). No statistically significant differences were found in lumen gain (mean difference: 0.15 mm²; CI 95%: −0.17 a 0.48; I² = 59%) or procedural success rate (OR: 2.04; CI 95%: 0.34–12.45; I² = 66.8%). Mortality was comparable between the groups (OR: 0.55; IC 95%: 0.28–1.06; I² = 1%).
Conclusion
IVL was associated with significant reduction of contrast use and procedure duration. Even though there were no differences in lumen gain or mortality, IVL appears as an effective strategy, especially in patients with kidney failure or complex coronary lesions. However, confirming these benefits at long term requires further randomized studies.
Reference: Ricardo Fonseca Oliveira Suruagy‐Motta et al. Catheterization and Cardiovascular Interventions, 2025; Volumen 1–10 DOI: 10.1002/ccd.31591.
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