Abstract
BACKGROUND: Coronary arterial calcification impedes safe and predictable percutaneous coronary intervention (PCI), and guidelines recommend calcium modification. Several interventional techniques exist, but the most optimal technique remains unclear. The aim of this study was therefore to assess the effects of PCI strategies for calcified lesions on all-cause mortality and serious adverse events. METHODS: A systematic review with meta-analysis and trial sequential analysis of randomised trials was conducted to compare any lesion preparation or stenting technique in patients undergoing PCI for moderately or severely calcified coronary lesions according to a published protocol. CENTRAL, MEDLINE, Embase and other sources were searched up to 8 May 2025. RESULTS: Out of 7,172 identified records, 31 eligible trials (8,453 participants) assessed 16 lesion preparation techniques (4,392 participants) and five stenting/scaffold techniques (4,061 participants). Lesion preparation comparisons were generally underpowered, and all showed no effect on all-cause mortality or serious adverse events. For stenting strategies, meta-analysis and trial sequential analysis showed that an effect of stent polymer coating (bioresorbable, permanent or polymer-free) on all-cause mortality or serious adverse events could be rejected. CONCLUSION: For patients undergoing PCI for moderately or severely calcified coronary lesions, there appears to be no significant differences between lesion preparation techniques regarding all-cause mortality or serious adverse events. Current evidence is underpowered and of low certainty, highlighting the clinical equipoise between available calcium modification techniques and the necessity for adequately powered randomised trials.