Comparison between advanced calcium modification techniques and balloon angioplasty for PCI requiring calcium modification: a systemic review and meta-analysis

Coronary calcification remains a major determinant of procedural failure during percutaneous coronary intervention (PCI). Advanced calcium modification techniques, including rotational atherectomy, orbital atherectomy, and intravascular lithotripsy (IVL), have been increasingly employed to optimize stent deployment and expansion. However, the comparative efficacy of these techniques versus conventional or modified balloon angioplasty has been evaluated in only a limited number of randomised controlled trials (RCTs).

This systematic review and meta-analysis aimed to evaluate procedural and clinical outcomes of advanced calcium modification techniques compared with conventional or modified balloon angioplasty in patients undergoing PCI.

A comprehensive search of MEDLINE, Embase, and the Cochrane Library was conducted to identify relevant studies. Eligible studies included RCTs and observational studies comparing advanced calcium modification techniques – rotational atherectomy, orbital atherectomy, or IVL – with conventional or modified balloon angioplasty. Studies lacking a direct comparator arm were excluded. The primary endpoint was procedural success, defined as successful deployment of the drug-eluting stent (DES) in the target lesion. Secondary endpoints included angiographic complications (perforation, dissection, and no-flow/slow-flow) and major adverse cardiac events (MACE), defined as a composite of all-cause death, periprocedural myocardial infarction, and target lesion failure. The review protocol was registered in PROSPERO (CRD420251168800).

Nine studies met the inclusion criteria, comprising four RCTs and five observational studies, with a total of 3,462 patients – 1,660 treated with advanced calcium modification and 1,802 with conventional or modified balloon angioplasty. Procedural success was significantly higher in the conventional/modified balloon angioplasty group (OR 2.06, 95% CI 1.17–3.66; p=0.01). Rates of angiographic complications were comparable between groups (OR 1.06, 95% CI 0.55–2.05, p=0.85). MACE incidence was significantly lower in the conventional/modified balloon angioplasty group (OR 1.70, 95% CI 1.09–2.64; p=0.02).

Conventional or modified balloon angioplasty was associated with superior procedural success and lower rates of major adverse cardiac events compared with advanced calcium modification strategies such as rotational atherectomy, orbital atherectomy, and IVL. These findings highlight the necessity for large, adequately powered RCTs to better define the optimal approach for calcium modification in contemporary PCI practice.

Forest plot showing procedural success