Initial cases indicate lithotripsy can help TCAR expand into high-risk patients

Kathryn DiLosa

Lithotripsy may hold the key to enabling more carotid artery disease patients who require calcification treatment to undergo stent placement via a transcarotid artery revascularisation (TCAR) procedure, as per single-centre experiences presented at the recent Society for Clinical Vascular Surgery (SCVS) annual symposium (25–29 March 2023, Miami, USA) by Kathryn DiLosa with principal investigator Misty Humphries (both University of California Davis, Sacramento, USA).

In cases of circumferential or eccentric calcification, TCAR is precluded and carotid endarterectomy (CEA) often becomes the preferred approach—however, in patients considered ‘high risk’ due to their anatomy or prior surgeries, for example, “another alternative exists”, the speaker averred.

Detailing the use of intravascular lithotripsy (IVL; Shockwave Medical) prior to a TCAR procedure, DiLosa noted that predilation angioplasty may be required to allow passage of a lithotripsy balloon, and the balloon “should be sized to fully oppose the vessel wall, but not extend past the intended coverage area”.

She further stated that lithotripsy technologies have been used in the treatment of kidney stones previously, and are now shifting into the endovascular space as well.

The speaker also reported a 100% rate of technical success with this approach at her institution, across a total of seven patients, with comparable procedural and flow-reversal times to standard TCAR, and no observed complications within 30 days of the procedure.

“However, a larger cohort [of patients] is still needed to confirm safety,” DiLosa said.

Responding to an audience query on how lithotripsy is able to successfully break up calcium without leading to embolisation—a concern she admitted to having initially herself—DiLosa added that “all of the available literature has demonstrated that it is able to fracture the calcium, within the wall, without it embolising from the wall”.

Briefly touching on the available literature regarding pre-TCAR lithotripsy, she stated that case studies—but no significant case series—are available at this point, although she and her colleagues are currently compiling a multi-institutional cohort including more than 50 patients.

“This is definitely for a specific patient population—those who cannot tolerate endarterectomy, but that would need the benefit of calcification [treatment],” DiLosa concluded.


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