Comparative Outcomes of Rotational Versus Orbital Atherectomy in Calcified Coronary Lesions: An Updated Systematic Review and Meta-Analysis.

Severe coronary artery calcification (CAC) can complicate percutaneous coronary intervention (PCI) and is associated with less favourable procedural and clinical outcomes. Rotational atherectomy (RA) and orbital atherectomy (OA) are established calcium-modification strategies used to facilitate PCI in heavily calcified lesions. This systematic review and meta-analysis evaluated the comparative clinical and procedural outcomes of RA and OA in patients with severe CAC. This systematic review and meta-analysis was conducted in accordance with PRISMA 2020 guidance. PubMed, EMBASE, and CENTRAL were searched from inception to July 2026 for studies directly comparing RA and OA in patients undergoing PCI for severe CAC. Eligible studies were synthesised quantitatively where appropriate and narratively otherwise. Risk of bias was evaluated using the Newcastle-Ottawa Scale for observational studies and the Cochrane Risk of Bias 2 tool for the randomised controlled trial. No statistically significant differences between RA and OA were identified for short-term major adverse cardiovascular events (MACE), short- or long-term all-cause mortality, cardiac mortality, long-term nonfatal myocardial infarction (MI) or short-term target vessel revascularisation (TVR). Compared with OA, RA was associated with higher odds of long-term MACE (OR 1.51, 95% CI 1.01-2.26), short-term nonfatal MI (OR 1.77, 95% CI 1.05-2.98) and long-term TVR (OR 2.51, 95% CI 1.12-5.64). Conversely, coronary dissection occurred less frequently with RA (OR 0.38, 95% CI 0.20-0.72). There were no significant between-group differences in cardiac tamponade, device-induced coronary perforation, slow-flow/no-reflow, fluoroscopy time or contrast volume. In this updated meta-analysis of more than 80,000 patients, OA was associated with lower pooled rates of long-term MACE, short-term nonfatal MI and long-term TVR, whereas RA was associated with a lower rate of coronary dissection. No consistent difference in all-cause mortality was demonstrated. Given the predominantly observational evidence base, these associations should not be interpreted as evidence of causal superiority, and device selection should remain individualised according to lesion characteristics, intravascular imaging findings and operator expertise.