A Quicker Pace: Shockwave Lithotripsy Pacing With Electromechanical Capture

Intravascular lithotripsy during percutaneous coronary intervention: current concepts

INTRODUCTION

Coronary artery calcification (CAC) is commonly encountered by interventional cardiologists. Severe CAC may impair stent delivery or result in stent underexpansion, stent thrombosis and/or in-stent restenosis (ISR). Multiple tools have been developed to help overcome the challenges associated with CAC and improve outcomes for these patients. Intravascular shockwave lithotripsy (IVL) is a novel therapy that uses acoustic pressure waves for the modification of CAC.

AREAS COVERED

This review discusses the growing body of evidence to support the safety and efficacy of IVL in the setting of de novo severely calcified coronary arteries prior to stenting. We also discuss international real world experience with the coronary IVL system. This includes the use of IVL in the setting of acute coronary syndrome (ACS), ISR and in combination with other tools for calcium modification.

EXPERT OPINION

IVL is a safe and effective therapy that results in the fracture of coronary calcium and facilitates optimal stent delivery and expansion. Longer term follow up is essential to shed light on the durability and late outcomes of an IVL strategy. Randomised control trials are warranted to compare IVL to alternative methods of calcium modification and to explore further the use of IVL for ACS.

Shockwave Intravascular Lithotripsy for the Treatment of Severe Vascular Calcification

Vascular calcification is a highly prevalent pathophenotype that is associated with aging, atherosclerotic cardiovascular disease, diabetes mellitus, and chronic kidney disease. When present, it portends a worse clinical outcome and predicts major adverse cardiovascular events. Heavily calcified coronary and peripheral artery lesions are difficult to dilate appropriately with conventional balloons during percutaneous intervention, and the use of several adjunctive strategies of plaque modification has been suggested. Intravascular lithotripsy (IVL) offers a novel option for lesion preparation of severely calcified plaques in coronary and peripheral vessels. It is unique among all technologies in its ability to modify calcium circumferentially and transmurally, thus modifying transmural conduit compliance. In this article, we summarize the currently available evidence on this technology, and we highlight its best clinical application through appropriate patient and lesion selection, with the main objective of optimizing stent delivery and implantation, and subsequent improved short- and long-term outcomes. We believe that the IVL balloon will transform the market, as it is easy to use, with predictable results. However, cost-effectiveness of such advanced technology will need to be considered.

The Coronary Intravascular Lithotripsy System

Calcified lesions often mean percutaneous intervention results are suboptimal and increase the risk of procedural complications and future adverse events. Available plaque-modifying devices rely on tissue compression or debulking, with the intention of fracturing calcium and facilitating optimal stent deployment. In contrast, coronary intravascular lithotripsy delivers unfocused, circumferential, pulsatile mechanical energy to safely disrupt the calcium within the target lesion. The present review summarises the evidence available so far on this therapy and includes a practical description of the components and function of the Shockwave Intravascular Lithotripsy System (Shockwave Medical).