Case report A 76-years old male patient presented 5 years after carotid stenting with ipsilateral recurrent high-grade stenosis, occlusion of the contralateral ICA and bilateral borderzone infarcts. A progressive cuff of calcification was identified with compression of the distal stent (see figure 1).
Due to previous neck radiation surgery was deemed contraindicated and endovascular therapy was chosen. Balloon angioplasty and repeat stenting were performed. However, postinterventional sonography revealed a persisting high-grade stenosis with peak systolic velocity of 412 cm/s.
After consideration of all treatment options, intravascular lithotripsy (IVL) with consecutive balloon angioplasty was performed using a 5.0 x 60 mm IVL system, a 5.0 x 20 mm angioplasty balloon and proximal balloon protection. An almost complete resolution of the stenosis could be achieved (see figure 2a and 2b). No complications were observed. Postinterventional sonography confirmed the treatment success. The patient was discharged four days after IVL without new neurologic deficits.
Discussion IVL uses focused ultrasound impulses to fracture calcified plaques and may expand the spectrum of therapeutic options for patients with calcified plaque and contraindication to surgery. Reported adverse events include adverse events known from angioplasty without IVL.
In this case surgery was not recommended and balloon angioplasty with repeat stenting had failed. Furthermore, treatment must target a calcified lesion. Thus, IVL has successfully been carried out as bail out from a double bind situation.
Disclosure of Interest Nothing to disclose
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