Efficacy of intravascular lithotripsy (IVL) in coronary stenosis with severe calcification: A multicenter systematic review and meta‐analysis

Background With heavily calcified coronary and peripheral artery lesions, lesion preparation is crucial before stent placement to avoid underexpansion, associated with stent thrombosis or restenosis and patency failure in the long‐term. Intravascular lithotripsy (IVL) technology disrupts superficial and deep calcium by using localized pulsative sonic pressure waves, making it to a promising tool for patients with severe calcification in coronary bed. Aims The aim of the study is to systematically review and summarize available data regarding the safety and efficacy of IVL for lesion preparation in severely calcified coronary arteries before stenting. Methods This study was conducted according to the PRISMA guidelines. We systematically searched PubMed, SCOPUS, and Cochrane databases from their inception to February 23, 2023, for studies assessing the characteristics and outcomes of patients undergoing IVL before stent implantation. The diameter of the vessel lumen before and after IVL, as well as stent implantation, were analyzed. The occurrence of major adverse cardiovascular events (MACE) was assessed using a random‐effects model. Results This meta‐analysis comprised 38 studies including 2977 patients with heavily calcified coronary lesions. The mean age was 72.2 ± 9.1 years, with an overall IVL clinical success of 93% (95% confidence interval [CI]: 91%−95%, I 2 = 0%) and procedural success rate of 97% (95% CI: 95%−98%, I 2 = 73.7%), while the in‐hospital and 30‐days incidence of MACE, myocardial infarction (MI), and death were 8% (95% CI: 6%−11%, I 2 = 84.5%), 5% (95% CI: 2%−8%, I 2 = 85.6%), and 2% (95% CI: 1%−3%, I 2 = 69.3%), respectively. There was a significant increase in the vessel diameter (standardized mean difference [SMD]: 2.47, 95% CI: 1.77−3.17, I 2 = 96%) and a decrease in diameter stenosis (SMD: −3.44, 95% CI: −4.36 to −2.52, I 2 = 97.5%) immediately after IVL application, while it was observed further reduction in diameter stenosis (SMD: −6.57, 95% CI: −7.43 to −5.72, I 2 = 95.8%) and increase in the vessel diameter (SMD: 4.37, 95% CI: 3.63−5.12, I 2 = 96.7%) and the calculated lumen area (SMD: 3.23, 95% CI: 2.10−4.37, I 2 = 98%), after stent implantation. The mean acute luminal gain following IVL and stent implantation was estimated to be 1.27 ± 0.6 and 1.94 ± 1.1 mm, respectively. Periprocedural complications were rare, with just a few cases of perforations, dissection, or no‐reflow phenomena recorded. Conclusions IVL seems to be a safe and effective strategy for lesion preparation in severely calcified lesions before stent implantation in coronary arteries. Future prospective studies are now warranted to compare IVL to other lesion preparation strategies.