The use of intravascular lithotripsy for the treatment of severely calcified lower limb arterial CTOs.

The endovascular management of complex lower limb arterial occlusive disease is generally associated with poorer acute results, a higher incidence of provisional stenting and subsequent restenosis compared to more simple arterial lesions. Even more challenging results can be expected when two complex features are combined such as chronic total occlusion (CTO) and severe calcification. Intravascular lithotripsy (IVL) with the Shockwave™ system has recently been evaluated as a familiar angioplasty-balloon-based but effective technique for the management of arterial calcification. In the DISRUPT PAD clinical trials, excellent acute results were obtained in moderate to severely calcified femoro-popliteal lesions, including a group of patients with CTOs. The incidence of provisional stenting was very low, despite the lesion complexity. There was a high incidence of subsequent restenosis, suggesting an anti-restenotic therapy with drug coated balloon is a necessary adjunct. This is being currently assessed in the DISRUPT PAD III randomized trial. There has also been positive experience in calcified tibial artery CTOs in the DISRUPT BTK trial and further clinical experience is currently being accumulated.