Aortoiliac calcification hindering cardiac interventions: A case for intravascular lithotripsy

Aortic calcification is associated with an increased risk of major adverse cardiovascular events, and while cases have been reported for its management, no expert consensus or guidelines currently exist. An 81-year-old male presented with recurrent falls and was diagnosed with severe symptomatic aortic stenosis (AS) and coronary artery disease (CAD) requiring high-risk percutaneous coronary intervention (PCI) and transcatheter aortic valve replacement (TAVR). Severe aortoiliac calcifications complicated clinical decision-making, posing a challenge to large-bore sheath placement. After heart-team review, shockwave intravascular lithotripsy (IVL) with bilateral 7×60 mm balloons was utilized to deliver sonic pressure waves at low inflation pressures to selectively fracture intimal and medial calcium. Improved vessel compliance facilitated Impella-assisted PCI and staged TAVR. This case demonstrates that IVL may be a viable option for aortic calcification when alternative approaches are limited. Its familiar balloon-based design and low-pressure inflation enhance its appeal. While procedural vascular risks do exist, they remain low and can be minimized with proper device sizing and technique.