Comparison between angiography or intravascular imaging guided coronary rotational atherectomy

Background Rotational atherectomy (RA) is a cornerstone technique for the management of severely calcified coronary lesions during percutaneous coronary interventions. Although intravascular imaging (IVI) provides superior anatomical guidance, its long-term prognostic impact in RA remains underexplored. Objectives This study aimed to compare 12-month clinical outcomes between IVI-guided and coronary angiography (CAG)-guided RA. Methods This retrospective analysis included 468 patients who underwent RA. Following 1:1 propensity score matching（PSM）, 306 patients (153 per group) were compared: IVI-guided versus angiography (CAG)-guided RA. The primary endpoint was 12-month major adverse cardiac events (MACE). A stratified Cox proportional hazards model, incorporating variables selected via least absolute shrinkage and selection operator (LASSO) regression, was employed for the primary adjusted analysis to mitigate overfitting. Results Compared with CAG guidance, IVI-guided RA was associated with the use of larger burrs and stent diameters, as well as greater contrast volume (all P <0.05). At 12 months, IVI-guided RA was associated with significantly lower rates of MACE (7.2% vs. 15.0%; P = 0.033), cardiac death (2.0% vs. 8.5%; P = 0.020), and all-cause mortality (2.6% vs. 11.8%; P <0.005). In the stratified multivariable Cox model adjusting for preoperative renal function, IVI guidance remained independently associated with a lower hazard of MACE (adjusted hazard ratio [HR] 0.42, 95% confidence interval [CI] 0.20–0.86; P = 0.018). Conclusions In this observational study, IVI-guided RA was associated with reduced 12-month MACE and all-cause mortality compared to CAG-guided RA. These findings generate hypotheses regarding the potential role of IVI guidance in this high-risk setting and underscore the need for validation in prospective, randomised trials.