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Use Of Lithotripsy For Treatment Of Circumferential Calcification During TCAR For High-risk Patients
Kathryn DiLosa, MD, MPH, Matthew Vuoncino, MD, Joel Harding, DO, Mimmie Kwong, MD, MAS, Steven Maximus, MD, Misty D. Humphries, MD, MAS.
UC Davis, Sacramento, CA, USA.

OBJECTIVES: The advent of transcarotid artery revascularization (TCAR) introduced a safe alternative to traditional endarterectomy (CEA) among high-risk patients. Utilization of this technology has been limited by anatomy and in the setting of severe eccentric or circumferential calcification within target vessels. Here we describe intravascular lithotripsy prior to stenting in patients with traditionally prohibitive calcific disease.
METHODS: We retrospectively identified six patients who underwent TCAR with concomitant intravascular lithotripsy for circumferential or eccentric carotid calcification between 2020-2022. In all cases, intravascular lithotripsy was combined with balloon angioplasty for treatment of severely calcified carotid vessels prior to deployment of a stent. Patient demographics, procedural details and safety were reported.
RESULTS: Six patients (67% Male, 7710 years) underwent TCAR, three (50%) for symptomatic disease. (Table 1) All patients had anatomical factors or comorbid conditions necessitating TCAR over traditional CEA. Anatomic factors included a contralateral carotid occlusion (N=1, 17%), or high cervical stenosis (5, 83%), and comorbid conditions included age greater than 75 years (3, 50%), congestive heart failure (1, 17%), severe COPD (1, 17%), or uncontrolled diabetes (2, 33%). Four patients (67%) had eccentric calcification, four (67%) had nearly circumferential calcification. The mean calcific lesion thickness was 3.65 mm (range 2.3-6.3). Mean procedure time was 10627 minutes, with a mean flow reversal time of 3425 minutes (range 8-77). Excluding the first procedure which occurred early in our institutional use of intravascular lithotripsy, mean flow reversal time was 2515 minutes. The most common lithotripsy and angioplasty balloon diameters were 4 mm (range 2.5-5.5 mm) and 5mm (range 4-7 mm), respectively. Mean hospital stay was 2.3.5 days, with an ICU stay of 1.7.5 days. Technical success was achieved in 100% of cases. There were no perioperative complications during the index hospitalization or stent related complications including restenosis, stroke, or dissection on duplex ultrasound at 1 month follow up.
CONCLUSIONS: Ours is the first reported series of intravascular lithotripsy as a supportive adjunct for TCAR in the setting of severe calcific disease. In our experience, intravascular lithotripsy sufficiently remodels calcified carotid vessels to facilitate stent deployment for treatment of carotid disease in high-risk patients.

Table 1: Patient characteristics
CharacteristicN (%)
Age, yearsAge >70 years77 10 years4 (67)
Male sex4 (67)
Hypertension6 (100)
Coronary artery disease5 (83)
Diabetes2 (33)
Chronic renal insufficiency0 (0)
Arrhythmia3 (50)
Congestive Heart Failure2 (33)
COPD1 (17)
Prior Coronary Intervention1 (17)
Race
White5 (83)
Black1 (17)
Asian0
Native American0
Pacific Islander0
Other0
Ethnicity
Hispanic0
Non-Hispanic6 (100)


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