Background: Percutaneous coronary intervention (PCI) of lesions with severe coronary artery calcification (CAC) is associated with a worse clinical outcome. Different techniques, such as rotational atherectomy (RA), orbital atherectomy (OA) and high-pressure balloon dilatation have been established to treat CAC but met some limitations. Compared to standard balloon (scoring or cutting), RA and OA are associated with higher procedural success but increased procedural risk. Coronary intravascular lithotripsy (IVL) is a recently-approved, novel ultrasound-based tool allowing for simple and safe treatment of CAC. Whether IVL has similar procedural success compared to RA is unknown. We report our single-center experience regarding feasibility, safety of IVL, in-hospital major adverse cardiac events (MACE) and revascularization rate comparing RA with IVL for the treatment of severe CAC.

Patients and Methods: We retrospectively analyzed the feasibility, efficacy and safety of IVL compared to RA in patients (pts) with severe CAC in our center. Both methods were applied in pts with a clinical PCI indication and required to have >1 target lesion with a diameter stenosis >70% and CAC as assessed by the interventionalist. The decision to use either RA or IVL was left to the operator. Angiographic results were quantified by Fractional Flow Reserve (FFR) or diastolic Flow Ratio (dFR) in angiographic intermediate lesions and procedure-related and in-hospital complications were recorded.

Results: 12 pts treated with IVL during 12 months were compared to 12 pts treated with RA. Median age was 81 years and 76 years for RA and IVL, respectively. 50% of pts treated with RA and 33.3% of pts treated with IVL were female. Diabetes mellitus was present in 41.6% of IVL and 33.3% of RA pts (p=n.s.). All pts had a previous attempt with PCI which failed due to suboptimal initial balloon pre-dilation. 66.7% and 91.7% of the patients had 3-vessel-disease for RA and IVL, respectively (p=n.s.). 50% in the IVL group presented with non-ST segment elevation myocardial infarction (NSTEMI), versus 33.3 % in the RA group (p=n.s.). Mean fluoroscopy time was significantly higher in the RA group (median [interquartile range = IQR] 27.0 [23.0;33.8] min) compared to the IVL group (median [IQR] 20.0 [18.0;25.5] min; p=0.03). However, the amount of contrast medium used did not differ between groups (RA: median [IQR] 222.5 [124.3;270.0] ml; IVL: median [IQR] 174.0 [138.0;203.5] ml; p=n.s.). Temporary pacemaker implantation was used in 33.3% in RA vs 8.3% in IVL (p=.n.s.). Procedural success was 83.3% in the IVL group versus 83.3% in the RA group. There were no in-hospital major adverse events and repeat revascularization during hospitalization was not required in both groups.

Conclusion: In this small single-center observational analysis IVL was safe and effective to treat highly calcified coronary lesions. Sine the procedural setup is easier in IVL and fluoroscopy time lower, it might become a valuable adjunct to PCI for severe CAC.