Comparative Performance of Calcium-Modification Strategies for Coronary Lesions: A Network Meta-Analysis of Randomized Trials.

INTRODUCTION AND OBJECTIVES: Calcified coronary lesions are associated with an increased risk of percutaneous coronary intervention (PCI) failure. Despite the availability of several calcium-modification strategies and randomized trials evaluating their efficacy, comparative investigations remain scanty. The aim of the present analysis is to assess the comparative performance of calcium-modification strategies in patients undergoing PCI of calcified coronary lesions. METHODS: We conducted a systematic search for randomized trials evaluating calcium-modification strategies in patients undergoing PCI. Random-effects network meta-analyses were performed. The primary outcome was minimal stent area (MSA). Secondary outcomes included all-cause death and stent thrombosis. RESULTS: Twenty-two trials enrolling 4855 patients were included. Compared to calcium modification with noncompliant balloons, the use of cutting/scoring balloon (mean difference: 0.81 mm2, 95% confidence interval: [0.36, 1.27]; p = 0.001), super high-pressure balloon (SHPB, 0.95 mm2 [0.18, 1.72]; p = 0.016), intravascular lithotripsy (IVL, 0.87 mm2 [0.40, 1.34]; p < 0.001), rotational atherectomy (RA, 0.90 mm2 [0.30, 1.50]; p = 0.003), and RA plus cutting balloon (1.24 mm2 [0.46, 2.02]; p = 0.002) led to larger MSA. According to a network ranking analysis, RA, SHPB, and IVL were possibly the best treatment options in terms of MSA. There were no significant differences in clinical outcomes between calcium-modification strategies. CONCLUSIONS: Compared with standard noncompliant balloons, RA and balloon-based strategies improved the mechanical performance of PCI in calcified coronary lesions. However, this did not result in better clinical outcomes.