Network meta-analysis of treatment strategies for calcified coronary lesions

Comparative evidence on treatment strategies for calcified coronary lesions (CCL) remains scarce, with few head-to-head trials and limited data on clinical outcomes. We conducted a frequentist network meta-analysis of randomized controlled trials (RCTs) comparing excimer laser (ELCA), lithotripsy (IVL), modified balloons (MBA), orbital atherectomy (OA), rotational atherectomy (RA), and RA plus cutting balloons (RA plus CBA) against a conventional strategy (CS). The primary endpoints were severe adverse events (SAE: death, coronary perforation, or slow-flow/no-reflow) and minimum stent area (MSA), while secondary endpoints included major adverse cardiovascular events (MACE) and target lesion revascularization (TLR). Fourteen RCTs including 3,671 patients were analyzed. Atherectomy-based strategies carried a higher risk of SAE versus CS, driven by slow-flow/no-reflow phenomenon. All strategies except OA and ELCA significantly increased MSA compared with CS, with the largest effect observed for RA plus CBA (MD 0.93 mm²; 95% CI 0.48-1.38). None of the strategies reduced MACE or TLR versus CS, although RA plus CBA ranked highest for both endpoints. IVL improved MSA (MD 0.59 mm²; 95% CI 0.14-1.03) without increasing SAE and ranked favorably for MACE and TLR, with the highest probability of lower mortality. Stand-alone MBA remained low-ranked for TLR, and sensitivity analysis confirmed its inferior MSA performance versus IVL. In summary, upfront plaque-modification improved MSA compared with a conventional strategy, although this gain did not translate into significant reductions in MACE or TLR, likely reflecting the limited number of events. RA plus CBA had the highest likelihood of lower MACE and TLR despite higher procedural risk, whereas IVL provided the most favorable balance between safety and efficacy.