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Aims Percutaneous coronary interventions (PCI) in calcified coronary artery lesions are associated with impaired stent expansion, higher rate of periprocedural complications and cardiac mortality. Lesion preparation using calcium modifying techniques such as Rotational Atherectomy (RA) or Intravascular Lithotripsy (IVL) has been advocated. Studies comparing these technologies are lacking. We aimed to compare the in-stent pressure gradient, evaluated by virtual fractional flow-reserve, in calcific lesions treated using either RA or IVL. Methods and results Patients undergoing either RA- or IVL-assisted PCI from two European centres were included. Propensity score matching (1:2) was performed to control for potential bias. Primary outcome was post-PCI in-stent pressure gradient calculated by virtual fractional flow reserve (vFFRgrad). Secondary outcomes included the proportion of patients with complete functional revascularization defined as of distal vFFR post PCI (vFFRpost) ≥0.90. From a cohort of 210 patients, 105 matched patients (70 RA and 35 IVL) were included. Pre-PCI vFFR did not differ between groups (0.65 ± 0.13 RA and 0.67 ± 0.11 IVL). After PCI, in-stent pressure gradients was significantly lower in the IVL group (0.032 ± 0.026 vs. 0.043 ± 0.026 in the RA group, P = 0.024). The proportion of vessels with functional complete revascularization was similar between the two groups (32.9% vs. 37.1% in the RA and IVL group, respectively; P = 0.669). Conclusions Calcific lesions preparation with IVL is effective and resulted in improved in-stent pressure gradient compared to RA. Approximately one third of the patients undergoing PCI for a severely calcified lesion achieved functional revascularization with no difference between rotational RA and IVL. 662 FigureIn stent gradients after RA and IVL. (A) Box plot depicting the distribution of the in-stent pressure gradient vFFRgrad between the two groups. (B) Cumulative frequency distribution curves demonstrating lower vFFRgrad after intravascular lithotripsy compared to rotational atherectomy. RA, rotational atherectomy; IVL, intravascular lithotripsy; vFFRgrad, in-stent pressure gradient.

662 Physiological and angiographic outcomes of PCI in calcified lesions after rotational atherectomy or intravascular lithotripsy