Technical and Target Lesion Failure in Calcified Coronary Lesions: Residual Risk Beyond Successful Lithotripsy

Intravascular lithotripsy (IVL) has been demonstrated effective and safe in the treatment of balloon-crossable calcified coronary lesions. However, a significant subset of patients still experiences suboptimal technical results and subsequent target lesion failure (TLF), leaving a gap in our understanding of procedural success drivers.

This study sought to identify factors independently associated with technical failure and 12-month TLF in calcified coronary lesions treated with IVL-assisted percutaneous coronary intervention.

From the multicenter BENELUX-IVL registry (NCT06577038), we included patients with complete quantitative coronary analysis. The primary technical endpoint was technical failure (unsuccessful IVL delivery, residual stenosis >30%, or procedural complications). The primary clinical endpoint was 12-month TLF (cardiac death, target-vessel myocardial infarction, or ischemia-driven revascularization).

A total of 571 patients (including 595 target lesions) were included. Technical failure occurred in 60 (10.5%) of the lesions, whereas 12-month TLF was reported in 41 (7.2%) cases. Multivariable analysis identified multivessel disease (OR: 1.39; 95% CI: 1.02-1.90), in-stent lesions (OR: 1.94; 95% CI: 1.14-3.30), and the absence of intravascular imaging (OR: 1.95; 95% CI: 1.13-3.40) as independent determinants of technical failure. Left circumflex (HR: 2.97; 95% CI: 1.49-5.92), in-stent target lesions (HR: 2.01; 95% CI: 1.02-3.52), technical failure (HR: 2.42; 95% CI: 1.26-4.61), diabetes mellitus (HR: 2.35; 95% CI: 1.23-4.47), reduced estimated glomerular filtration rate (HR: 0.98; 95% CI: 0.97-0.99), and younger age (HR: 0.95; 95% CI: 0.92-0.98) emerged as factors independently associated with TLF.

Our findings demonstrate that residual risk in IVL-assisted percutaneous coronary intervention is driven by a distinct interplay of modifiable and nonmodifiable factors, rather than inherent limitations of the technology itself.