Procedural and Clinical Outcomes After Orbital Atherectomy Versus Intravascular Lithotripsy in Patients With Calcified Nodules

BACKGROUND: Calcified nodules (CNs) remain a major challenge in percutaneous coronary intervention (PCI). We sought to compare procedural and clinical outcomes after orbital atherectomy (OA) versus intravascular lithotripsy (IVL)-facilitated PCI in patients with CNs. METHODS: We identified patients with optical coherence tomography (OCT)-defined CNs who underwent PCI with either OA or IVL between 2012 and 2022 and had both pre- and post-PCI OCT images available. The imaging end point was the minimal stent area on final post-PCI OCT. The clinical end point was 2-year target-lesion failure, a composite of cardiac death, target-vessel myocardial infarction, or clinically driven target-lesion revascularization. A multivariable Cox proportional hazards regression model was used to estimate hazard ratio and 95% CI. Sensitivity analyses were performed using propensity score matching, incorporating covariates such as age, sex, diabetes, and pre-PCI calcium burden assessed by OCT (length, arc, and thickness). RESULTS: Among 4856 patients with evaluable pre- and post-PCI OCT images, 493 patients (10.2%) had CNs, and 167 patients underwent PCI with either OA (n=83) or IVL (n=84). The 2 groups had similar baseline demographic and lesion characteristics. After PCI, final minimal stent area was comparable between the 2 groups (OA, 5.6 mm 2 [interquartile range, 4.8–6.7] versus IVL, 5.5 mm 2 [interquartile range, 4.8–7.0]; P =0.75). At a median follow-up of 2.4 years, there was no difference in target-lesion failure between the OA and IVL groups (12.0% versus 9.8%, respectively; log-rank P =0.64; adjusted hazard ratio, 1.10 [95% CI, 0.28–4.31]; P =0.89). Overall results remained consistent in the propensity score-matched population (n=68 per group), with similar minimal stent area (5.6 mm 2 [4.8–6.7] versus 5.5 mm 2 [4.7–6.8]; P =0.73) and comparable 2-year target-lesion failure rate (9.8% versus 8.8%; log-rank P =0.82). CONCLUSIONS: In patients with OCT-defined CNs, OA- and IVL-assisted PCI resulted in comparable post-PCI minimal stent area and 2-year clinical outcomes.