Intravascular Lithotripsy Is Associated With Superior Clinical Outcomes Compared to Atherectomy: A Large-Scale, Propensity-Matched Analysis.

BACKGROUND

Coronary artery disease (CAD) with severe calcification remains a growing challenge in percutaneous coronary intervention (PCI). Atherectomy (ATH) has long been used for plaque modification, whereas intravascular lithotripsy (IVL) has emerged as a promising alternative. Large-scale comparative data on long-term outcomes are limited.

AIMS: To compare 1-year clinical outcomes, 30-day procedural complications, and temporal trends between IVL and ATH use.

METHODS

We conducted a retrospective cohort study using the TriNetX Research Network, analyzing de-identified data from 47 health care organizations. Adults with CAD undergoing single-vessel PCI with drug-eluting stent (DES) and either IVL or ATH were included. Outcomes were assessed after propensity matching, and annual utilization trends were evaluated from 2013 to 2024.

RESULTS

We identified 13,499 patients who underwent DES with IVL (n = 7026) or ATH (n = 6473). After matching, 5768 patients remained in each cohort. At 1 year, IVL was associated with lower risk of all-cause mortality (RR 0.64; 95% CI 0.58-0.72; p < 0.0001), myocardial infarction (RR 0.80; 95% CI 0.66-0.96; p = 0.0166), and MACE (RR 0.71; 95% CI 0.62-0.82; p < 0.0001). IVL also reduced 30-day procedural complications (RR 0.77; 95% CI 0.61-0.97; p = 0.0271), with less bleeding (RR 0.44; 95% CI 0.31-0.62; p < 0.0001) and CA-AKI (RR 0.71; 95% CI 0.55-0.91; p = 0.0068). IVL use increased rapidly and surpassed ATH after 2022.

CONCLUSION

In this large, real-world registry, IVL was associated with more favorable 1-year outcomes and fewer 30-day complications than ATH. These findings support IVL as a safe and effective alternative for complex coronary lesions, emphasizing the need for validation in randomized trials to assess for causality.