Intravascular lithotripsy vs. rotational atherectomy for severely calcified coronary lesions with concomitant tortuosity or angulation: a propensity-weighted real-world study from China

Background Intravascular lithotripsy (IVL) is an emerging technique for the treatment of severely calcified coronary lesions, yet head-to-head evidence comparing its prognostic value against standard rotational atherectomy (RA) in real-world practice, particularly in patients with tortuous or angulated coronary anatomy, remains lacking. Methods This retrospective observational cohort study included 247 patients with severely calcified coronary lesions and concomitant tortuous or angulated anatomy who underwent percutaneous coronary intervention between January 2023 and March 2025, comprising 137 patients treated with RA and 110 treated with IVL. The primary endpoint was one-year composite major adverse cardiovascular events (MACE), encompassing all-cause mortality, target vessel revascularization, heart failure rehospitalization, in-stent restenosis, and stroke. Three complementary analytical strategies of escalating robustness, multivariable logistic regression, inverse probability of treatment weighting (IPTW) using a gradient boosted model (GBM), and doubly robust estimation, were employed to estimate the treatment effect of IVL vs. RA. Covariate balance was assessed using standardized mean differences (SMD ≤ 0.10). Results Baseline characteristics were broadly comparable between groups, with significant differences observed only in LDL-C, total cholesterol, and HDL-C (all P < 0.05). After IPTW, all 20 covariates achieved SMD ≤ 0.10. IPTW analysis demonstrated a significant 52% reduction in the odds of MACE with IVL (OR 0.48, 95% CI 0.25–0.90; P < 0.05), with directionally consistent estimates from multivariable logistic regression (OR 0.49, 0.18–1.23; P = 0.14) and doubly robust estimation (OR 0.48, 0.18–1.25; P = 0.13). Among secondary outcomes, one-year heart failure rehospitalization was significantly lower with IVL (OR 0.22, 95% CI 0.03–0.78; P = 0.03); no significant differences were observed for mortality, target vessel revascularization, stroke, or in-stent restenosis. Conclusions In this retrospective cohort of patients with severely calcified coronary lesions, all of whom had concomitant tortuous or angulated anatomy, IVL was associated with a lower risk of one-year MACE compared with RA, an effect driven primarily by a reduction in heart failure rehospitalisation. The consistency across three analytical models suggests robustness of this finding, although confirmation in adequately powered randomised controlled trials is warranted.