Adjunctive Intravascular Lithotripsy with Carotid Angioplasty Reduces Adverse Events

Introduction Heavily calcified carotid stenosis (HCCS) has been considered an exclusion criteria for carotid angioplasty and/or stenting (CAS), amenable to only carotid endarterectomy. We analyze whether intravascular lithotripsy (IVL) utilizing the Shockwave S 4 intravascular lithotripsy (IVL) system (Shockwave® Medical Inc.) as an adjunct to CAS improves radiological and clinical outcomes for HCCS compared CAS without adjunctive IVL. Materials/Methods Patients with symptomatic or asymptomatic de novo HCCS undergoing CAS were included. Charts were reviewed for demographic, imaging, procedural, and outcome data. The primary endpoint was composite major adverse event (MAE) rate: death, ipsilateral stroke, or myocardial infarction (MI) within 30 days of CAS. Secondary endpoints included technical and procedural success, residual stenosis, and ISR incidence post‐procedure. The pre‐procedure NASCET stenoses in patients undergoing adjunctive IVL were fuzzy matched within a threshold of 0.1 to those without adjunctive IVL. Results We included 32 patients (35 carotids), with 18 patients (20 carotids) undergoing IVL+CAS. Prior to matching, conventional CAS cases showed higher pre‐procedure NASCET stenosis (74% vs. 60.3%, p<0.01), a trend toward higher post‐procedure residual stenosis (30.2% vs. 22.7%, p=0.06), and significantly higher ISR rates (40% vs. 0%, p<0.01). After matching, 29 patients (30 carotids) remained, with 15 patients (15 carotids) treated with IVL+CAS. Pre‐ and post‐procedure stenosis grades were similar between groups, yet ISR occurred significantly higher in the conventional CAS group (35.7% vs. 0%, p=0.02). Conclusion CAS with adjunctive IVL appears superior to conventional CAS for both symptomatic and asymptomatic HCCS, demonstrating higher freedom from major adverse events and mainly, in‐stent restenosis. These findings support IVL as a valuable adjunct, potentially broadening the applicability of CAS in managing challenging calcified carotid lesions.