Intravascular Lithotripsy Versus Rotational Atherectomy for Calcified Coronary Lesions: A Systematic Review and an Updated Meta‐Analysis of Clinical Outcomes

BACKGROUND: Severe coronary artery calcification (CAC) remains a significant challenge in interventional cardiology, especially in elderly and comorbid patients, such as diabetes or chronic kidney disease. CAC often leads to complications such as stent thrombosis and restenosis, therefore leading to bad clinical outcomes and increased major adverse cardiovascular events (MACE) rates. Traditional approaches, including rotational atherectomy (RA), are commonly used to treat calcified plaques; however, are limited by procedural complexity, length of procedures, and risk of vascular injury. In contrast, intravascular lithotripsy (IVL) has emerged as a novel therapy using acoustic pressure waves to break calcified plaques with minimal vascular trauma. Despite its increasing use, direct comparisons between IVD and RA in the context of severe CAC are scant and leave critical evidence gaps for therapy optimization. This study compares IVL and RA outcomes to improve strategies for severe CAC management. AIMS: This study aims at comparing the clinical outcomes such as procedural success, safety evaluations and clinical efficacy of IVL with RA in the treatment of severe CAC. METHODS: A systematic review and meta-analysis were conducted following PRISMA 2020 guidelines and registered in PROSPERO (CRD42024626551). Searches were performed in PubMed, ScienceDirect, Embase, and Scopus databases using the descriptors "Rotablator," "Lithotripsy," and "Coronary Disease" combined with Boolean operators ("AND" and "OR"). Eligible studies directly compared IVL and RA, assessing outcomes such as procedural success, safety, and efficacy. Inclusion criteria were directed to retrospective cohorts and randomized studies with at least 6 months of follow-up, excluding case reports, reviews, and conference abstracts. Two independent reviewers performed data extraction with a third resolving discrepancies. The ROBINS-I tool was used to assess the risk of bias in non-randomized studies, while statistical analyses were done using R software (version 4.3.2). RESULTS: Eleven studies with a total of 2120 patients were included. IVL demonstrated significant benefits over RA, such as reduced use of contrast (MD: -17.45 mL; 95% CI: -32.79 to -2.11) and lower procedural time (MD: -27.90 min; 95% CI: -30.11 to -25.68; I² = 92.3%). IVL also effectively treated complex lesions, such as bifurcations and calcified left main arteries, by fragmenting plaques with minimal vascular trauma and reduced procedural risks. While luminal gain showed no differences between groups (MD: -0.07 mm²; 95% CI: -0.34 to 0.35), IVL provided higher rates of stent deployment success and lower target lesion revascularization, indicating better long-term vessel patency. The meta-analysis for mortality outcome showed a pooled OR of 0.55 (95% CI: 0.28-1.06; I² = 1%; p = 0.42) under the common-effect model and 0.70 (95% CI: 0.35-1.42) under the random-effects model, with negligible heterogeneity (I² = 1%). These consistent findings across studies reinforce IVL as a safer and effective strategy for severe CAC and warrant further trials to establish long-term benefits. CONCLUSION: IVL showed slight advantages over RA in severe CAC, including reduced contrast use, shorter procedure times, and fewer complications. Further trials are needed to confirm these findings and to reduce the heterogeneity of the studies.