Coronary calcification is a major factor leading to stent under-expansion, and subsequent adverse events. This meta-analysis aimed to evaluate the short and long‑term outcomes of rotational atherectomy (RA), followed by modified balloon (cutting or scoring) (MB) versus plain balloon before drug‑eluting stent implantation for calcified coronary lesions. We searched PubMed, Web of Science (WOS), Scopus, and the Cochrane Library Central Register of Controlled Trials (CENTRAL), from inception until 30 January 2024. The risk ratio (RR) with a 95% confidence interval (CI) was used to compare dichotomous outcomes, while continuous outcomes were reported in form of mean difference (MD). Our study included seven studies with 309 patients undergoing RA followed by MB angioplasty, and 414 patients had RA followed by conventional plain balloon angioplasty, before stent implantation. Our analysis revealed no significant difference in-hospital mortality (RR = 0.64, 95% CI [0.18, 2.23], p = 0.49), or long-term mortality (RR = 0.65, 95% CI [0.18, 2.36], p = 0.51). MACE were significantly lower in the cutting balloon group (RR = 0.58, 95% CI [0.37, 0.92], p = 0.02). Angiographic minimum lumen diameter, and change in percent diameter stenosis were significantly higher in the MB group (MD = 0.19, 95% CI [0.08, 0.31], p = <
0.01), and (MD = 3.75, 95% CI [0.76, 6.74], p = 0.01) respectively. No difference was found regarding target lesion revascularization (RR: 0.50, 95% CI [0.24, 1.04], p = 0.06), or target vessel revascularization (RR: 0.71, 95% CI [0.38, 1.33], p = 0.28). RA followed by MB is as safe plain balloon angioplasty before stent implantation in moderate to severely calcified coronary lesions. Moreover, it is associated with significantly better immediate angiographic outcomes, and significantly lower MACE.