Browse the corpus

Shockwave intravascular lithotripsy is a novel device that modifies calcified lesions via calcium fracture to allow for effective stent deployment. This activity describes the procedure and reviews the role of the healthcare team in treating patients who undergo this procedure. Objectives: Describe the pathophysiology of coronary artery calcification. Identify the indications for shockwave intravascular lithotripsy. Review the technique for shockwave intravascular lithotripsy. Summarize the risks associated with shockwave intravascular lithotripsy. Access free multiple choice questions on this topic.

Coronary artery calcification (CAC) is an independent predictor for major cardiovascular events.[1][2][3][4] Additionally, coronary calcium deposition can hinder successful percutaneous coronary intervention (PCI) as a result of inadequate stent expansion, difficulty transiting the catheter through a calcified lesion, coated drug separation from a stent, proclivity for in-stent restenosis and stent thrombosis, and a change to the underlying pharmacokinetics. Consequently, PCI of calcified lesions correlates with worse outcomes.[5] Shockwave intravascular lithotripsy (IVL) is a novel technique evolved from the established therapy for renal and ureteral calculi that utilizes a percutaneous device to produce acoustic pressure waves resulting in the delivery of energy to break superficial and deep calcium deposits and aid with the subsequent deployment of a vascular stent.[6][7][8] Guidance with an intravascular imaging device either with intravascular ultrasound or optical coherence tomography is crucial in defining the calcium density and choosing the optimal lesion modification strategy, i.e., rotational atherectomy, orbital atherectomy or IVL.[9][10][11][12][13] The feasibility and safety of IVL in the peripheral vasculature was shown in the Disrupt Peripheral Arterial Disease (PAD) studies and the Disrupt Below the Knee (BTK) study.[14][15][16] The Disrupt PAD III study (ClinicalTrials.gov Identifier: NCT02923193) is currently an ongoing prospective multicenter single-arm observational study assessing treatment of moderate and severely calcified femoropopliteal arteries. The disrupt Coronary Artery Disease studies I and II demonstrated the safety and feasibility of IVL in calcified coronary lesions.[17][6] The Disrupt CAD III (ClinicalTrials.gov Identifier: NCT03595176) is an ongoing prospective, multicenter, single-arm study evaluating the safety and effectiveness of IVL in de novo calcified coronary arteries.

The use of IVL for management of calcified coronary lesions like other lithotripsy therapies may theoretically predispose to membrane depolarization; however, sufficient clinical data to support this is lacking at present. In addition, coronary artery perforation may occur due to barotrauma from either low-pressure balloon inflation or high energy acoustic wave emission, though rates have been low in clinical trials.

IVL is an important adjunctive tool in the cardiac catheterization laboratory that can be useful for lesion preparation and guidance of optimal percutaneous coronary interventions. Utilization of intravascular imaging modality is vital in defining the calcium density, depth, and circumferential extent and choosing optimal lesion modification strategy afterward and assessment for having achieved an adequate endpoint.