Introduction Coronary stenosis with severe calcification is a serious challenge for percutaneous coronary intervention. Coronary artery calcification interferes with stent expansion and catheter passage and leads to higher complications, such as target lesion failure, stent thrombosis, and cardiac mortality. There are multiple proposed modalities for calcium modification, such as intravascular lithotripsy (IVL) and rotational atherectomy. We aim to compare both techniques for calcified coronary artery disease. Methods We systematically searched PubMed, Scopus, Cochrane, and Web of Science from inception to January 2025. To estimate the effect size, dichotomous outcomes were pooled as odds ratio (OR), and continuous outcome was pooled as mean difference with their respective 95% confidence interval (CI). The prespecified primary endpoint was major adverse cardiovascular events (MACE; in‑hospital and longest reported follow‑up). Procedural success was a prespecified key secondary endpoint. Results Fifteen studies were included (rotational atherectomy: n = 1406; IVL: n = 1088). There was no difference in MACE in‑hospital (OR = 1.43, 95% CI: 0.63–3.22) or at longest follow‑up (OR = 0.93, 95% CI: 0.44–2.00). Procedural success favored IVL (OR = 0.57, 95% CI: 0.36–0.89). Safety endpoints favored IVL: rotational atherectomy was associated with more coronary perforation (OR = 2.67, 95% CI: 1.58–4.49) and slow flow/no‑reflow (OR = 2.49, 95% CI: 1.03–6.03). There were no differences in mortality (in‑hospital or long‑term), myocardial infarction (in‑hospital or long‑term), target vessel revascularization, or stent thrombosis. Procedure duration was shorter with IVL (mean difference: 13.79 min, 95% CI: 4.09–23.49). Conclusion IVL and rotational atherectomy are excellent options to be utilized in the plaque modification of calcified coronary artery lesions before drug-eluting stents implantation with comparable clinical safety and efficacy outcomes. Rotational atherectomy and IVL yielded comparable clinical outcomes for MACE. IVL was associated with higher procedural success, fewer periprocedural complications (perforation, slow flow/no‑reflow), and shorter procedures. However, the higher costs incurred by IVL represent a major drawback that limits the use and the standardization of such a technique in clinical practice.
Khalefa et al. (Tue,) studied this question.