Beyond calcium modification: Comparative evidence and disparities in access to intravascular lithotripsy, rotational atherectomy, and orbital atherectomy

Severely calcified coronary artery disease complicates percutaneous coronary intervention (PCI) by limiting lesion compliance, balloon expansion, stent delivery, and optimal stent deployment. This review compares intravascular lithotripsy (IVL), rotational atherectomy (RA), and orbital atherectomy (OA), focusing on their mechanisms, procedural characteristics, comparative evidence, and disparities in access. RA uses a high-speed diamond-coated burr to ablate calcified plaque, whereas OA uses an eccentrically mounted diamond-coated crown to modify calcium through orbital motion. IVL delivers acoustic pressure waves that fracture superficial and deep calcium without mechanically removing plaque. Recent randomized trials, including ROTA.shock, DIRO, and the three-arm ROLLER COASTR-EPIC22 trial (RA, IVL, and excimer laser coronary angioplasty [ELCA]), suggest that IVL achieves stent expansion comparable to RA in balloon-crossable lesions, while RA produced greater stent expansion than OA in one small trial, without established clinical superiority. However, available comparative studies remain limited by small sample sizes and reliance on imaging-based rather than clinical endpoints. Beyond procedural efficacy, contemporary U.S. data indicate disparities in the use of atherectomy and IVL associated with socioeconomic status, race, sex, insurance status, income, and geographic region. These disparities suggest that access to advanced calcium-modification technologies remains inequitable among patients with potentially treatable disease. Expanding equitable access will require improved reimbursement, referral pathways, regionalization of complex PCI, and broader availability of advanced devices at hospitals serving underserved populations. Future research should integrate comparative clinical outcomes with evaluation of the health-system and socioeconomic factors influencing technology access.