EuroPCR 2026 | Rotational atherectomy, orbital atherectomy, or lithotripsy: does device selection modify prognosis?

In the complex setting of severe coronary calcification, different plaque modification strategies have been incorporated into the therapeutic armamentarium, including rotational atherectomy (RA), orbital atherectomy (OA), and intravascular lithotripsy (IVL). However, their comparative impact on clinical outcomes remains under debate.

The FRACTURE-CALCIUM study was a systematic review and meta-analysis designed to evaluate the prognostic significance of these three plaque modification strategies in patients undergoing PCI. Patients treated for calcified coronary artery disease were included, comparing RA, OA, and IVL in terms of clinical and procedural outcomes. Based on randomized and observational studies, a total of 6,817 patients were analyzed: 4,339 treated with RA, 1,230 with OA, and 1,248 with IVL, with a mean follow-up of 8 months.

Regarding procedural outcomes, all three strategies demonstrated high success rates. Procedural success was 93.9% with RA, 94.2% with OA, and 89.4% with IVL.

Procedural complications were infrequent. The overall reported incidence was 2.14% for slow-flow/no-reflow, 0.42% for abrupt vessel closure, 1.97% for coronary dissection, and 1.68% for vessel perforation. When comparing the different strategies, procedural safety was considered comparable among devices, although the authors noted a trend toward lower slow-flow/no-reflow incidence with IVL versus RA.

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In clinical outcomes, compared with RA, no significant differences in MACE were observed for either IVL or OA, with ORs of 0.896 (95% CI 0.636-1.26) and 0.849 (95% CI 0.625-1.15), respectively.

Sensitivity analyses were consistent across subgroups with follow-up longer than one year, de novo lesions, and chronic coronary syndromes, without demonstrating a clear signal of clinical superiority for any strategy over another.

Conclusion: RA, OA, and IVL showed comparable clinical outcomes in severely calcified coronary lesions

This represents the largest meta-analysis to date comparing RA, OA, and IVL in PCI for calcified coronary artery disease. The data demonstrate that all three strategies achieve high procedural success, low complication rates, and no significant differences in MACE at a mean follow-up of 8 months.

Reference: Presentado por Filippo Luca Gurgoglione en EuroPCR 2026 Late-Breaking Trials, 19-22 de mayo de 2026, París, Francia.