Background: Intravascular lithotripsy (IVL) is a novel calcium modification strategy with little evidence of efficacy compared to widely used rotational atherectomy (RA). Aims: We sought to compare the efficacy and safety level between IVL and RA in moderate-to-severe coronary artery calcification (CAC). Methods: We searched three databases until March 2025 for eligible observational studies and randomized controlled trials. The primary endpoint was major adverse cardiac event (MACE) while secondary endpoints were clinical outcomes, periprocedural complication, and procedural outcomes. Mantel-Haenszel risk ratio (RR) was used for dichotomous endpoints, and inverse variance mean difference (MD) for continuous variables, both with 95% confidence interval (CI). Results: Seven observational studies and two randomized clinical trials (RCT) with 968 patients were included; 418 IVL-treated patients and 550 RA-treated patients. IVL is associated with lower risk of MACE (IVL 1.5% vs. RA 5.3%; RR: 0.34 CI: 0.13–0.87) and all-cause mortality (IVL 1.6% vs. RA 5.4%; RR: 0.35 CI: 0.15–0.81) in in-hospital outcome. However, assessed with longer follow-up, IVL developed comparable risk of MACE (IVL 4.3% vs. RA 7.7%; RR 0.70 CI: 0.42–1.18) compared to RA while all-cause mortality remained lower in IVL (2.5% vs. 7.0%; RR: 0.41 CI: 0.22–0.78). No significant differences were observed in the risk of myocardial infarction (p = 0.58), nor in the risk of dissection (p = 0.52), perforation (p = 0.22), or slow/no-reflow (p = 0.07). IVL likewise demonstrated comparable procedural performance, including procedural success, angiographic success, fluoroscopy duration, and procedural time. Conclusion: IVL has similar outcomes to RA in terms of procedure outcomes and periprocedural complications. However, IVL is associated with lower all-cause mortality and MACE specifically in short term outcomes. © The Author(s) 2026.