The treatment of calcified coronary lesions remains one of the most technically challenging scenarios in contemporary angioplasty. In this context, intravascular lithotripsy (IVL) and cutting balloon (CB) represent two widely used plaque-modifying strategies. The relative efficacy of both techniques may depend not only on calcium severity, but also on its morphology and the concomitant use of atherectomy.
The IVUS substudy of the ShortCUT Trial evaluated whether the performance of cutting balloon versus IVL remained consistent across different patterns of coronary calcification. The study included 413 patients with calcified coronary artery disease undergoing IVUS-guided PCI. Patients were stratified according to the initial plan for rotational atherectomy: 208 patients with planned atherectomy and 205 without planned atherectomy. Within each stratum, patients were randomized 1:1 to CB or IVL, followed by DES implantation. The primary endpoint was postprocedural minimum stent area (MSA) at the site of maximal calcification. Secondary endpoints included calcium fracture, stent expansion percentage, and procedural cost.
In the nodular calcium analysis, no significant differences were observed in the overall cohort between IVL and CB regarding MSA: 8.2 ± 2.1 mm² vs 9.2 ± 2.6 mm², respectively (p=0.25). There were also no differences in stent expansion or calcium fracture. However, procedural cost was significantly higher with IVL (USD 18,833 vs USD 10,958; p<0.001). In the subgroup without planned atherectomy, IVL was associated with greater MSA in nodular calcium lesions: 9.6 ± 3.0 mm² vs 7.6 ± 1.5 mm² (p=0.04).
Regarding the analysis according to calcium arc, in the 360° calcium arc cohort, IVL demonstrated greater MSA compared with CB: 8.6 ± 2.4 mm² vs 7.8 ± 2.3 mm² (p=0.007), with an even more pronounced difference in patients without planned rotational atherectomy (8.9 ± 2.2 mm² vs 7.4 ± 1.8 mm²; p=0.001). Conversely, in lesions with calcium arc <360°, no significant differences were observed in MSA, stent expansion, or calcium fracture in the overall cohort, although procedural cost remained consistently higher with IVL across all analyses.
In patients treated with upfront rotational atherectomy, differences between IVL and cutting balloon were less evident. The “Rota-Cut” strategy showed comparable results to “Rota-Shock” across the different morphologies analyzed, with lower procedural cost.
Conclusion: IVL showed advantages in complex calcium without prior atherectomy
In this IVUS substudy of the ShortCUT Trial, the choice between IVL and cutting balloon appears to depend on the pattern of calcification and the use of rotational atherectomy. In more complex calcium lesions, such as 360° arc or nodular calcium, IVL achieved greater MSA in patients without planned atherectomy. In contrast, after upfront rotational atherectomy, the addition of CB provided results comparable to IVL with lower procedural cost.
Original Title: Subestudio IVUS del ShortCUT Trial.
Reference: Presentado por Suzanne J. Baron en Late-breaking trials, EuroPCR 2026, 19-22 de mayo de 2026, París, Francia.
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