Abstract 11830: Intravascular Lithotripsy versus Balloon-Based and Atherectomy Lesion Preparation for Calcified Coronary PCI: A Bayesian Meta-Analysis of Randomized Trials

Background: Coronary artery calcification impairs lesion preparation and stent deployment during percutaneous coronary intervention (PCI). Intravascular lithotripsy (IVL) has emerged as a novel calcium-modifying strategy and represents a less aggressive alternative to balloon-based preparation and rotational atherectomy (RA). However, randomized evidence comparing these approaches remains limited, and probabilistic estimates of treatment effects are scarce. Research Question: Among patients undergoing PCI for calcified coronary lesions, does IVL improve procedural and clinical outcomes compared with balloon-based strategies or RA? Methods: A systematic search of PubMed, Embase, and Cochrane databases identified randomized controlled trials comparing IVL with balloon-based strategies or RA before drug-eluting stent implantation in calcified coronary lesions. Bayesian random-effects meta-analyses were performed using vague priors for treatment effects and empirical or weakly informative priors for between-study heterogeneity. Outcomes included minimal stent area (MSA), stent expansion, and major adverse cardiovascular events (MACE). Results were reported as mean differences (MDs) or odds ratios (ORs) with 95% credible intervals (CrIs). Prediction intervals, posterior probabilities, sensitivity analyses, and leave-one-out analyses were performed. Results: Seven RCTs comprising 574 patients were included. Compared with balloon-based PCI, IVL demonstrated a 92.6% posterior probability of benefit for MSA (MD 0.91 mm 2 , 95% CrI 0.13 to 1.70) and an 86.1% posterior probability of improved stent expansion (MD 3.17%, 95% CrI –1.68 to 8.03). No clear benefit was observed for MACE (OR 0.93, 95% CrI 0.32 to 2.67). Compared with RA, IVL showed no credible differences in MSA (MD –0.28 mm 2 , 95% CrI –0.94 to 0.39), stent expansion (MD –0.89%, 95% CrI –4.55 to 2.76), or MACE (OR 3.03, 95% CrI 0.65 to 14.11). Similarly, when compared with all pooled PCI strategies, IVL was not associated with credible superiority for MSA (MD 0.44 mm 2 , 95% CrI –0.63 to 1.54), stent expansion (MD 0.88%, 95% CrI –3.84 to 4.89), or MACE (OR 1.40, 95% CrI 0.55 to 3.60). Findings were consistent across sensitivity and leave-one-out analyses. Conclusions: In patients undergoing PCI for calcified coronary lesions, IVL was associated with a favorable posterior estimate for MSA compared with balloon-based strategies, while demonstrating broadly comparable procedural and clinical outcomes to RA. These findings suggest that IVL may represent a feasible alternative for calcium modification, although larger randomized studies are needed to clarify its relative clinical benefit.