Intravascular lithotripsy in acute coronary syndromes: a scoping review of procedural success and clinical outcomes

Abstract Background Coronary artery calcification is present in up to 30–40% of lesions undergoing PCI and contributes to adverse outcomes. Intravascular lithotripsy (IVL) is established for lesion preparation in stable, calcified coronary disease; however, its role in acute coronary syndromes (ACS) remains poorly characterized, as these patients were largely excluded from pivotal trials. Current ESC guidelines recognize IVL as an option for calcium modification but provide no formal recommendation regarding its use in ACS. Purpose To systematically map and evaluate the existing evidence on the use of IVL in patients presenting with ACS. Methods Following PRISMA-ScR guidelines, MEDLINE, Embase, and CENTRAL were searched from inception to October 2025 for studies reporting outcomes of IVL in ACS patients. Data on device success, procedural success, and major adverse cardiac events (MACE) were extracted and synthesised narratively. Device success was defined as successful delivery and activation of the IVL balloon at the target lesion. Procedural success was defined as 20–30 % residual stenosis with final TIMI 3 flow and absence of in-hospital major MACE. MACE was defined as the composite of death, myocardial infarction, or target-vessel revascularisation and reported at 30 days and 12 months when available. Results Of 1,180 records, three studies met the inclusion criteria, comprising 948 (ACS = 540) patients. The REPLICA-EPIC18 registry (n = 422) included 265 ACS cases (32 STEMI, 169 NSTEMI, 64 unstable angina); the BENELUX-IVL registry (n = 454) included 203 ACS cases (33 STEMI, 114 NSTEMI, 56 unstable angina); and Cosgrove et al. 2021 (n = 72) enrolled STEMI-only patients. Across studies, the mean age ranged from 72.9 to 76.3 years, with male sex comprising 70–85 % of participants. Device success exceeded ≥97.5 % of all cases across all studies, reported at 99.1 % in REPLICA-EPIC18, 97.5 % in BENELUX-IVL, and 100 % in Cosgrove et al. Procedural success ranged from 69 % to 100 %, reported at 69 % in REPLICA-EPIC18, 89.1 % in BENELUX-IVL, and 100 % in Cosgrove et al. Thirty-day MACE ranged from 3.9 % to 18 %, reported at 4.5 % in REPLICA-EPIC18, 3.9 % in BENELUX-IVL, and 18 % in Cosgrove et al. Twelve-month MACE was reported only in BENELUX-IVL at 7.9 %. Conclusion Current evidence for IVL use in ACS derives solely from real-world registries. While initial results are promising, heterogeneity in study design and reporting limits definitive conclusions. Dedicated randomized trials are needed to establish safety, efficacy, and optimal use of IVL in the ACS population.Bar charts Procedural Success and 30-day PRISMA flowchart