Use of Intravascular Lithotripsy for Severe Calcification in Endovascular Aortoiliac Reconstruction

Purpose: Arterial calcification is common in peripheral arterial disease, often resulting in suboptimal clinical outcomes after angioplasty and stent placement. The use of intravascular lithotripsy (IVL) to create microfractures within the calcification may increase luminal patency and prevent stent under expansion. We detail usage of IVL in the distal abdominal aorta (AA) during an endovascular aortoiliac (AI) reconstruction of Trans-Atlantic Inter-Society Consensus Document (TASC) D lesions.

Materials and Methods: A 62-year-old woman with rest pain and left lower extremity claudication presented for percutaneous transluminal angioplasty of the iliac artery. The first attempt was prematurely terminated 1 month earlier because of severe back and knee pain, requiring general anesthesia for the second attempt. Right brachial retrograde access (RA) was performed followed by placement of a sheath in the infrarenal abdominal aorta. An aortogram revealed a 3- to 4-cm occlusion of the distal AA, extending into bilateral CIAs and the left EIA. Collateral circulation was provided by hypertrophied iliolumbar and inferior mesenteric vessels. Calcified plaque was seen in the right common femoral artery (CFA), resulting in 85% stenosis. Chronic occlusion of the right superficial femoral artery (SFA) was present, and the right CIA was conventionally cannulated. A shockwave IVL device was initially used in the right CFA to allow safe non–flow-limiting RA via the proximal right SFA. A loop-snare was then used to pass a wire from the right SFA access point into the abdominal aorta across the right CIA occlusion. Subintimal cannulation of the long segment left distal AA, CIA, and EIA occlusion via the brachial sheath was successful. Intravascular ultrasound (IVUS) ensured reentry into the EIA true lumen above the inguinal ligament crossover. Kissing shockwave balloon (SB) angioplasty was used in the distal AA and CIAs. SBs were also used in the left EIA. Significant luminal gain was noted after SB angioplasty; however, kissing-covered stents at the AI bifurcation and left EIA were needed based on angiography and IVUS.

Results: Significantly decreased flow through collaterals and excellent luminal patency were seen angiographically and on IVUS. Pulses were palpable, and the patient reported immediate relief in symptoms.

Conclusions: IVL can serve as a useful tool in modifying, normally resistant calcified plaque morphology to improve angiographic results and ultimately clinical outcomes. This has been documented in other lower extremity vessels but less so in AI occlusive disease.