Efficacy Intravascular Lithotripsy Compared with Rotational/ Orbital Atherectomy in Stent Restenosis: A Systematic Review

Background: Severe coronary artery calcification (CAC) poses a major challenge during percutaneous coronary intervention (PCI) and increases the likelihood of in-stent restenosis (ISR). Rotational atherectomy (RA) and intravascular lithotripsy (IVL) are widely used plaque-modifying strategies, yet clear guidance on selecting between them remains limited. This systematic review compares the efficacy of RA and IVL in the management of ISR, focusing on patient characteristics, lesion morphology, procedural performance, and clinical outcomes. Methods: A systematic search was conducted in PubMed, the Cochrane Library, and Google Scholar for studies published from January 2020 to April 2025. The review adhered to PRISMA 2020 guidelines. Inclusion criteria comprised angiographically confirmed coronary ISR treated with RA or IVL and reported angiographic or clinical outcomes. Both randomized and observational studies were eligible. Data extraction encompassed study characteristics, procedural parameters, complications, and short- to mid-term outcomes. A qualitative synthesis was performed due to heterogeneity in study design and reported endpoints. Results: Nine studies involving 1,250 patients met the eligibility criteria. Procedural success was consistently high (95–100%) for both modalities. IVL demonstrated numerically fewer procedural complications in several reports, particularly vessel perforation and slow/no-reflow (RA 3–13% vs. IVL 0–3%), although pooled results did not reach statistical significance. Rates of major adverse cardiac events (MACE) during follow-up were comparable between groups (RA 6–18% vs. IVL 5–17%). RA was more frequently employed in densely calcified lesions requiring substantial plaque debulking, whereas IVL tended to be favored in cases prioritizing procedural safety. Conclusion: RA and IVL are effective strategies for treating calcified ISR after PCI. Selection should be individualized based on lesion complexity, plaque morphology, and procedural risk. Additional high-quality studies are needed to refine modality-specific indications and establish long-term comparative outcomes.