Intravascular lithotripsy in comparison to rotational atherectomy for calcified lesions: the ICARE OFDI randomised trial

Benjamin Honton¹, MD; Pascal Motreff², MD, PhD; Jean-Sébastien Mallet³, MD; Thomas Hovasse⁴, MD; Matthieu Godin⁵, MD; Guilhem Malclès⁶, MD; Jerome Brunet⁷, MD; Nicolas Meneveau⁸, MD, PhD; Pierre Deharo⁹, MD, PhD; Benoit Lattuca¹⁰, MD, PhD; Erwan Bressollette¹¹, MD; Michael Angioi¹², MD; Hakim Benamer⁴^,¹³, MD; Edouard Gerbaud¹⁴, MD, PhD; Bruno Pereira¹⁵, PhD; Vincenzo Cesario¹, MD, PhD; Antoine Poinas², MD; Clémence Laperche¹, MD; Antoine Sauguet¹, MD; Géraud Souteyrand², MD; Nicolas Amabile⁴, MD, PhD; Nicolas Combaret², MD

Abstract

Background: The management of calcified coronary lesions remains challenging. Although several devices for advanced plaque modification are available, their relative efficacy is debated.

Aims: We aimed to compare intravascular lithotripsy (IVL)- and rotational atherectomy (RA)-based strategies for calcified plaque preparation during percutaneous coronary interventions (PCI).

Methods: This multicentre, prospective, randomised non-inferiority trial compared IVL with RA for plaque preparation in moderate-to-severe stable calcified coronary lesions. All interventions were guided by optical frequency domain imaging. A non-inferiority margin of 0.75 mm² was prospectively defined based on prior intracoronary imaging studies, and the sample size calculation was based on a standard deviation of 1.9 mm², a one-sided alpha risk of 5%, and a power of 80%, under the assumption of no true difference between groups. The primary endpoint was the minimal stent area (MSA) following stent implantation. The target lesion failure (TLF) rate was analysed after 12 months.

Results: A total of 169 patients (RA: n=86, IVL: n=83; 81.1% male; median age 71.8±8.2 years) were included in the final analysis. The baseline characteristics of each group were balanced. Calcified nodules were identified in 48% of the patients. IVL was not inferior to RA for the primary endpoint (6.0±2.3 mm² vs 5.9±2.2 mm², respectively; p for non-inferiority <0.05). Adequate geometrical stent expansion was similar in both groups (RA: 65.1%, IVL: 65.1%; p=0.994), whereas major strut malapposition were more frequently observed in the RA group (RA: 80.2% vs IVL: 57.8%; p=0.002). There was no difference between groups in terms of periprocedural complications. The TLF rates between groups after 12 months were equivalent (RA: 1.2%, IVL: 2.4%; p=0.61).

Conclusions: In this trial, the IVL strategy was non-inferior to the RA strategy regarding MSA for PCI in moderate-to-severe calcified coronary lesions, with a comparable safety profile and equivalent clinical outcomes.

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