Abstract Body (Do not enter title and authors here): Background: Traditional plaque-modification strategies such as rotational atherectomy (RA) have long served as a cornerstone in managing these lesions, despite limitations including operator dependency, risk of slow flow, and distal embolization. In contrast, intravascular lithotripsy (IVL) has recently emerged as a novel, less aggressive modality using acoustic pressure waves to fracture intimal and medial calcium while preserving vascular integrity. This study aims to compare the clinical and procedural outcomes of IVL versus RA in patients undergoing PCI for calcified coronary artery disease.

Methods: A comprehensive search of Web of Science, PubMed, Scopus, and Cochrane databases was conducted from inception to January 2025 to identify studies comparing IVL and RA for clinical and procedural outcomes in patients with calcified coronary artery disease. Dichotomous outcomes were pooled as risk ratios (RRs), and continuous outcomes as mean differences (MDs), both with 95% confidence intervals (CIs). All analyses were performed using R Studio version 4.3.2.

Results: Fifteen studies were included in this meta-analysis. RA was associated with a significantly higher risk of coronary perforation (OR = 2.67; 95% CI (1.58, 4.49); P < 0.01) and slow flow/no-reflow (OR = 2.49; 95% CI (1.03, 6.03); P = 0.04) compared to IVL. Additionally, RA was linked to a lower rate of procedural success (OR = 0.57; 95% CI (0.36, 0.89); P = 0.01) and a longer procedural duration (MD = 13.79 minutes; 95% CI (4.09, 23.49); P < 0.01). However, there were no significant differences between RA and IVL in terms of target vessel revascularization (OR = 0.37; 95% CI (0.04, 3.20); P = 0.37), or target lesion revascularization (OR = 0.72; 95% CI (0.22, 2.33); P = 0.59). Also, there were no significant differences in terms of in-hospital mortality, long-term mortality, in-hospital myocardial infarction, and long-term myocardial infarction. Furthermore, the change in minimal lumen diameter did not differ significantly between the two modalities (MD = -0.06 mm; 95% CI (-0.25, 0.12); P = 0.52).

Conclusion: IVL demonstrates a superior safety profile and procedural efficiency over RA in treating calcified coronary lesions, with reduced rates of perforation and slow flow, and higher procedural success. While long-term clinical outcomes remain comparable, IVL aligns better with contemporary interventional cardiology goals emphasizing vessel preservation and procedural predictability.