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Abstract
Introduction/Purpose Large, calcified plaques that narrow the vessel lumen and involve more than half of the carotid artery circumference pose an endovascular treatment challenge. Such lesions are prone to technical failure. Some patients may not be surgical candidates and may benefit from intravascular lithotripsy. Intravascular lithotripsy (IVL) is currently approved for treatment of severely calcified coronary lesions but may be used in the carotid artery to break up the calcium build up in the vessel wall prior to carotid stenting. IVL use for carotid stenosis treatment represents an off-label use of the device.
Materials and Methods Retrospective review of our carotid artery stenting database and identification of all patients in whom IVL was used prior to carotid stent placement between August 2021 and July 2021. Patient characteristics, procedural details and patient follow-up information was collected.
Results In 7 patients (2 females) with mean age of 73 years (range 64-86 years) IVL was used prior to carotid artery stenting. All carotid stenoses were severely calcified with degree of stenosis greater than 70%. One patient showed restenosis after previous carotid endarterectomy (CEA). Cerebral protection devices (CPD) were used in 6 of the 7 cases. In one case the CPD could not be advanced beyond the calcified stenosis. A carotid Wallstent was placed in 6 cases and an Xact stent in 1 case. Post-stent angioplasty was performed in 3 cases. No procedural complications were seen. Follow-up 3 to 8-month carotid Duplex evaluations was available in all patient (5 carotid Duplex exams and 2 CT angiogram follow-ups). Carotid Duplex showed a patent stent in 4 cases (80%) and 1 case with new, 75% in-stent stenosis - in the patient who already underwent CEA and presented with re-stenosis. This patient underwent re-treatment with balloon angioplasty. CT angiogram follow-up questioned in-stent narrowing in both follow up cases but patients remained asymptomatic. Subsequent angiogram evaluations showed minimal in-stent hyperplasia not warranting intervention.
Conclusion IVL is a novel technique that simplifies endovascular carotid stenting procedures in previously known challenging conditions. This technique minimizes the risk of complications and optimizes patient outcomes with promising early imaging follow-up. Severely calcified and/or circumferential carotid artery lesions with plaques protruding into the vessel lumen may be more easily amenable for endovascular treatment in the future.
Disclosures A. Kuhn: None. J. Singh: None. S. Sarid: None. M. Garcia: None. A. Puri: 1; C; NIH, Microvention, Cerenovus, Medtronic Neurovascular and Stryker Neurovascular. 2; C; Medtronic Neurovascular, Stryker NeurovascularBalt, Q’Apel Medical, Cerenovus, Microvention, Imperative Care, Agile, Merit, CereVasc and Arsenal Medical. 4; C; InNeuroCo, Agile, Perfuze, Galaxy and NTI.