Intravascular Lithotripsy in the modification of calcified nodules: A Meta-Analysis

Abstract Introduction Calcified nodules (CNs) are increasingly recognized as critical contributors to acute coronary syndrome, yet available treatment options for this condition remain limited. Intravascular Lithotripsy (IVL) disrupts both superficial and deep calcium, enabling uniform modification of CNs and adjacent calcified plaque segments. Methods Following PRISMA guidelines, we systematically searched PubMed, SCOPUS, and Cochrane databases up to February 3, 2025, for studies evaluating the safety and efficacy of IVL in treating CNs. We extracted angiographic (QCA) and intracoronary imaging (OCT or IVUS) data, assessing lumen characteristics before and after IVL, as well as post-stenting outcomes. The primary efficacy endpoint was procedural success, while safety endpoints included peri-procedural complications, in-hospital/30-day mortality, long-term mortality, and major adverse cardiovascular events (MACE: death, myocardial infarction, or target vessel revascularization). Results This meta-analysis comprised 6 studies including 148 patients and 204 treated CNs with IVL. The mean age was 70.8 ± 9 years, with an overall IVL procedural and device success rate at 100% (95% Confidence Interval (CI): 98%-100%, I²=0%). No in-hospital/30-days MACE occurred with only 3 deaths, 2 MIs and 2 target vessel revascularizations being reported during 1 year follow-up. Immediately after IVL application, it was observed a significant increase in minimal lumen area (MLA) Standardized Mean Difference (SMD): +0.51 95% CI: 0.24 to 0.79, I²=0%) with an acute lumen gain of 0.67 ± 1.5mm. After stent implantation, the reference vessel diameter increased significantly (SMD): +0.48 (95% CI: 0.10 to 0.86%, I²=0%), along with minimal lumen diameter (MLD) (SMD: +3.13, 95% CI: 1.68 to 4.58, I²=83%). The mean stent expansion rate was 96 ± 22.3%, with a minimal stent area (MSA) of 6.9 ± 2.5 mm² and an acute lumen gain of 1.8 ± 0.8mm. Peri-procedural complications such as dissections, occurred in 14% of cases (95% CI: 0%–39%, I²=90%), but no instances of stent thrombosis, perforation, or no-reflow phenomena were observed. Conclusions IVL appears to be a safe and effective strategy for managing CNs, demonstrating high procedural success, low MACE rates, and favorable intracoronary imaging outcomes. Future prospective studies are needed to compare IVL with other lesion preparation strategies.Procedural Success Dissections