Multicenter Experience With Intravascular Lithotripsy for Treatment of Severe Calcification During TCAR for High-risk Patients

Transcarotid artery revascularization (TCAR) offers a safe alternative to carotid endarterectomy (CEA), but severe calcification is currently considered contraindication. This study aims describe the safety and effectiveness of TCAR with intravascular lithotripsy (IVL) in patients traditionally prohibitive calcific disease. Patients who underwent TCAR+IVL between 2017 2022 at seven institutions were identified. IVL was combined predilatation angioplasty for treatment severely calcified vessels prior stent deployment. The primary outcome (freedom from stroke/transient ischemic attack [TIA]) secondary (technical success <30% residual stenosis). Forty-nine (61% male, 79 ± 6.9 years) TCAR+IVL, 20 (41%) symptomatic disease (Table I). All had high-risk anatomical factors or comorbid conditions favorable over CEA. Thirty-eight lesions, 10 (20%) eccentric, 18 (37%) circumferential, eccentric circumferential (20%). Mean lesion thickness 3.5 mm (range, 2.0-7.1 mm), mean preprocedure stenosis 86 9%. procedure flow reversal times 90 26 14 minutes. Average number pulses per case 115 30-330) contrast usage 30 mL. Poststent completed 21 (43%). No changes on electroencephalography new neurological deficits observed intraoperatively. Technical achieved 100% cases, 48 (98%) having (40% 1 case) completion angiography. Four stroke/TIA within days an overall rate 8% (2 vs nonstroke-TIA patients; P = .70). One TIA one stroke occurred during index hospitalization postprocedure two TIAs after discharge. Preoperative 93% (vs 86% nonstroke/TIA .35), chronic renal insufficiency higher (75% 24%; .01), anesthesia type (general local) significantly differed groups (50% general 84% cases; .05). Otherwise, there no differences calcium, procedural, patient characteristics compared cases II). follow-up 131 19-520). Three stents developed recurrent (6%) duplex; remainder patent without issue. In this multicenter series, sufficiently remodels arteries effectively facilitate However, appears be concern as than conventional CEA, which warrants further investigation.Table IPatient demographics criteria (n 49)DemographicsNo. (%)Age, years79 yearsMale sex30 (61)Race White46 (94) Black2 (4) Other1 (2)Ethnicity Hispanic4 (8) Non-Hispanic45 (92)High-risk Anatomical factorsContralateral occlusion4 (8)High cervical stenosis10 (20)Restenosis endarterectomy2 (4)Restenosis transcarotid arterial revascularization2 (4)Spine immobility8 (16)Hostile neck9 (18)Laryngeal palsy/laryngectomy3 (6)Permanent contralateral cranial nerve injury1 (2)Need major surgery2 (4)Tandem stenosis2 (4)Bilateral stenosis11 (22) Comorbid factorsN (%)Age >75 years31 (63)Renal insufficiency9 (18)Congestive heart failure5 (10)History coronary (≥2 vessels)13 (16)History angina11 (22)Abnormal stress test4 (8)Myocardial infarction >72 hours <6 weeks (4)Severe chromic obstructive pulmonary disease7 (14)Uncontrolled diabetes2 Open table tab Table IIComparison (TIA) + (IVL)Stroke/TIA 4), No. (%)Nonstroke/TIA 45), (%)P valueSymptomatic disease2 (50)18 (40).70Preoperative (%)9386.35Chronic insufficiency3 (75)9 (20).01Congestive failure1 (25)12 (27).94Coronary disease3 (75)36 (80).81Hypertension4 (100)42 (93).60Prior intervention3 (75)26 (58).50Arrhythmia1 (25)14 (31).80Chronic disease1 (25)8 (18).72Diabetes1 (27).94General anesthesia2 (50)39 (87).05Circumferential calcium2 (50)26 (58).76Eccentric calcium1 (25)19 (42).50Calcium thickness, mm33.6.99Mean time, minutes2426.98Mean minutes8890.64Pre-IVL angioplasty2 (40).70Post-IVL (50)17 (38).63Poststent (50)19 (42).76