Laser Versus Rotational Atherectomy in Coronary Artery Disease: A Systematic Review and Meta-Analysis of Procedural Success and Safety

The evolution of percutaneous coronary intervention (PCI) has improved the management of complex coronary lesions, particularly in heart failure patients. Laser atherectomy (LA) and rotational atherectomy (RA) are used to treat in-stent restenosis and calcified stenosis. Both techniques share similar indications and risks, but direct comparisons of their efficacy and safety are limited. This review examines procedural success, complication rates, and clinical outcomes of RA and LA. PubMed, Embase, and the Cochrane Library were searched to retrieve studies between 2015 and 2025. Primary outcomes included procedural success, major adverse cardiovascular events (MACE), and complications, including dissection and perforation. Random-effects models were used for analysis, with subgroup analyses based on lesion type and complexity. Fourteen studies were included in our meta-analysis (LA: 6 studies; RA: 8 studies). LA showed a procedural success rate of 96.3%, higher than RA (93.3%). The increase in lumen diameter after the procedure was statistically significantly higher in LA (mean difference: 6.71 mm²; 95% CI: (6.64-6.79); p < 0.001) as compared to RA (mean difference: -27.90 mm²; 95% CI: (-27.95,-27.85); p < 0.001). Subgroup analysis revealed that RA worked better on severely calcified lesions that required stentablation. Complication rates were similar between the two techniques (1.2% for LA vs. 1.5% for RA; p = 0.21). LA provides better procedural success and lumen gain in heart failure patients with complex coronary lesions. However, RA remains superior for stentablation in non-dilatable, calcified lesions. Both techniques have similar safety profiles, suggesting the need for individualized treatment based on patient and lesion characteristics.