Intravascular lithotripsy for calcified left main coronary artery disease - insights from a multicenter registry

Abstract Background/Introduction Severe calcification of the left main (LM) coronary artery remains a major challenge for percutaneous coronary interventions (PCIs), limiting optimal stent expansion and long-term outcomes. Intravascular lithotripsy has emerged as an effective and safe technique for calcium modification, yet evidence in left main lesions remains scarce. Purpose Our study aimed to evaluate procedural and clinical outcomes of IVL in patients undergoing LM PCI. Methods This multicenter, retrospective registry included 89 patients who underwent intravascular lithotripsy (IVL) for left main (LM) coronary artery disease between 2019 and 2025 at multiple interventional cardiology centers in Poland. The procedural success (primary efficacy endpoint) was defined as residual stenosis 20%. Secondary endpoints were target lesion revascularization (TLR), target vessel myocardial infarction (TV-MI), and cardiovascular death (CVD). Results The majority of patients were male (83.2%) with a mean age of 72.6 ± 7.8 years. Hypertension and hyperlipidemia were highly prevalent (83.9% and 86.2%, respectively), and over half of the cohort had a history of myocardial infarction (55.2%) or prior PCI (60.5%). Nearly half of patients (48.9%) presented with acute coronary syndrome, with a mean left ventricular ejection fraction of 42.5 ± 15.2%. The main indications for IVL were de novo calcification (71.9%), in-stent restenosis (21.4%), and stent underexpansion (6.7%). Intravascular imaging (IVUS or OCT) guidance was used in 79.6% of cases, and 91.9% of procedures involved the left main bifurcation. Mechanical circulatory support with Impella CP was used in 10.1% of procedures. Rotational atherectomy prior to IVL was performed in 11.4% of cases. The mean IVL balloon size was 3.4±0.5 mm. The mean preprocedural minimal lumen area (MLA) was 3.6 ± 1.6 mm². On average, 1.9 ± 1.4 calcium fractures were observed per lesion after IVL utilization. The mean final minimal stent area (MSA) was 9.0 ± 1.7 mm², resulting in acute lumen area gain of 5.35 ± 2.4 mm². Procedural success, defined as residual stenosis 20%, was achieved in 94.3% of cases, while final TIMI 3 flow was obtained in 98.9%. Periprocedural complications were infrequent (7.9%) and included dissection (3.4%), perforation (1.1%), and no-reflow (1.1%). At a median follow-up of 355 days, TLR occurred in 3.4%, TV-MI in 1.7%, and CVD in 15.3% of patients. Conclusions In this largest Polish registry of LM IVL to date, IVL has proven to be a safe and effective strategy for calcium modification in LM lesions, achieving high procedural success with a low rate of complications and optimal short and long-term outcomes. These findings support the expanding role of IVL in the treatment of calcified left main disease, particularly when guided by intravascular imaging.