E-22 | Comparative Effectiveness of Intravascular Lithotripsy Versus Atherectomy for Coronary Calcium Modification: A Target Trial Emulation

Background: Intravascular lithotripsy (IVL) and atherectomy are widely used plaque-modification strategies for heavily calcified coronary artery disease.Although comparative data continue to emerge, uncertainty remains regarding their relative effectiveness on ischemic and procedural outcomes in routine clinical practice.We emulated a pragmatic target trial to compare IVL with atherectomy using largescale real-world data.Methods: We emulated a predefined target trial using the TriNetX Analytics Network.Adult patients undergoing percutaneous coronary intervention with either IVL or atherectomy were identified.Treatment strategies were defined as assignment to IVL versus atherectomy at the index procedure.Extensive baseline covariates were balanced using 1:1 propensity score matching.The primary outcome was major adverse cardiovascular and cerebrovascular events (MACCE).Secondary outcomes included all-cause mortality, myocardial infarction (MI), repeat revascularization, in-stent restenosis (ISR), stroke, acute heart failure decompensation, coronary dissection, pericardial tamponade, and acute kidney injury (AKI).Effects were estimated using Cox proportional hazards models under an intention-to-treat framework.Results: After matching, 26,386 patients were included (13,193 IVL; 13,193 atherectomy).The mean age was 71.6 10.0 years, and 31% were female.Compared with atherectomy, IVL was associated with a higher risk of MACCE (HR 1.06, 95% CI 1.02-1.10;p=0.001).IVL was also associated with higher risks of MI (HR 1.05, 95% CI 1.01-1.10;p=0.015) and repeat revascularization (HR 1.28, 95% CI 1.20-1.38;p<0.001).There were no significant differences in all-cause mortality, ISR, stroke, acute heart failure decompensation, coronary dissection, pericardial tamponade, or AKI.Conclusions: In this large target trial emulation, IVL was associated with higher risks of MACCE, MI, and repeat revascularization compared with atherectomy, with no differences in mortality or major procedural complications.These findings suggest important modest differences between calcium-modification strategies and suggests the need for careful patient and lesion selection.