The epidemiology, pathophysiology, and novel treatment of calcific arterial disease

Endovascular treatment of arterial diseases has become first-line in most cases due to improved technology. However, until recently, excessive atherosclerotic calcification has been a major limiting factor in the endovascular management of peripheral arterial disease, as well as vascular access for endovascular aneurysm repair (EVAR) and transcatheter aortic valve replacement (TAVR). The Peripheral Intravascular Lithotripsy (IVL) System (Shockwave Medical, Inc., Fremont California) applies pulsatile mechanical energy under fluoroscopic guidance to disrupt calcified lesions. The purpose of this paper is to introduce IVL in the treatment of calcific access vessels in preparation for EVAR and TAVR, as well as peripheral arterial disease applications to enhance luminal gain. Using the IVL System, angioplasty can be performed with lower pressures, which may minimize arterial dissection. Further, the lithotripsy effect on calcium will enhance vessel compliance. We describe several cases where IVL was applied successfully and present additional cases that may have benefitted from the use of this technology.