Cracking Coronary Calcium With Intravascular Lithotripsy: A Review

Calcified coronary lesions (CCL) remain a major challenge in percutaneous coronary intervention, often limiting stent expansion and worsening long-term outcomes. Conventional calcium modification techniques such as specialty balloons or atherectomy may fail to adequately address heavily calcified lesions and are associated with procedural risks. Intravascular lithotripsy (IVL) has become an established calcium-modification strategy that uses acoustic pressure waves to fracture calcium while minimizing vessel trauma. This review summarizes evidence from pivotal trials and real-world experience demonstrating the safety and feasibility of IVL across a broad spectrum of lesion morphologies, including eccentric calcium, calcified nodules, and complex subsets such as left main disease. Comparative analyses with other calcium-modification modalities are presented, along with an imaging-guided, morphology-driven algorithm to inform contemporary device selection in routine practice. In conclusion, while IVL offers a safe and effective approach to lesion preparation, important limitations remain, including the lack of randomized comparative data and cost considerations. Ongoing trials are expected to further define its role, with current evidence supporting IVL as an important tool in the contemporary management of CCL.