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• W4377261985 abstract "Transcarotid artery revascularization (TCAR) offers a safe alternative to carotid endarterectomy (CEA), but severe calcification is currently considered a contraindication. This study aims to describe the safety and effectiveness of TCAR with intravascular lithotripsy (IVL) in patients with traditionally prohibitive calcific disease. Patients who underwent TCAR+IVL between 2017 and 2022 at seven institutions were identified. IVL was combined with predilatation angioplasty for treatment of severely calcified vessels prior to stent deployment. The primary outcome was safety (freedom from stroke/transient ischemic attack [TIA]) and the secondary outcome effectiveness (technical success and <30% residual stenosis). Forty-nine patients (61% male, 79 ± 6.9 years) underwent TCAR+IVL, 20 (41%) for symptomatic disease (Table I). All patients had high-risk anatomical factors or comorbid conditions favorable for TCAR over CEA. Thirty-eight patients had calcific lesions, 10 (20%) with eccentric, 18 (37%) with circumferential, and 10 with eccentric and circumferential calcification (20%). Mean calcific lesion thickness was 3.5 mm (range, 2.0-7.1 mm), with a mean preprocedure stenosis of 86 ± 9%. Mean procedure and flow reversal times were 90 ± 26 and 26 ± 14 minutes. Average number of lithotripsy pulses per case was 115 (range, 30-330) and mean contrast usage 30 mL. Poststent angioplasty was completed in 21 patients (43%). No patients had changes on electroencephalography or new neurological deficits observed intraoperatively. Technical success was achieved in 100% of cases, with 48 patients (98%) having <30% residual stenosis (40% residual stenosis in 1 case) on completion angiography. Four patients had a stroke/TIA within 30 days for an overall rate of 8% (2 symptomatic in stroke/TIA patients vs 20 symptomatic in nonstroke-TIA patients; P = .70). One TIA and one stroke occurred during the index hospitalization postprocedure and two TIAs occurred after discharge. Preoperative mean stenosis in stroke/TIA patients was 93% (vs 86% in nonstroke/TIA patients; P = .35), chronic renal insufficiency was higher (75% vs 24%; P = .01), and anesthesia type (general vs local) significantly differed between groups (50% general anesthesia in stroke/TIA vs 84% in nonstroke/TIA cases; P = .05). Otherwise, there were no observed differences in calcium, procedural, or patient characteristics compared to the nonstroke/TIA cases (Table II). The mean follow-up was 131 days (range, 19-520). Three stents developed recurrent stenosis (6%) on follow-up duplex; the remainder were patent without issue. In this multicenter series, IVL sufficiently remodels calcified carotid arteries to effectively facilitate TCAR in patients with traditionally prohibitive calcific disease. However, there appears to be a safety concern as the stroke/TIA rate is higher than in conventional TCAR or CEA, which warrants further investigation.Table IPatient demographics and high-risk criteria (n = 49)DemographicsNo. (%)Age, years79 ± 6.9 yearsMale sex30 (61)Race White46 (94) Black2 (4) Other1 (2)Ethnicity Hispanic4 (8) Non-Hispanic45 (92)High-risk criteria Anatomical factorsContralateral occlusion4 (8)High cervical carotid stenosis10 (20)Restenosis after prior carotid endarterectomy2 (4)Restenosis after prior transcarotid arterial revascularization2 (4)Spine immobility8 (16)Hostile neck9 (18)Laryngeal palsy/laryngectomy3 (6)Permanent contralateral cranial nerve injury1 (2)Need for major surgery2 (4)Tandem stenosis2 (4)Bilateral stenosis11 (22) Comorbid factorsN (%)Age >75 years31 (63)Renal insufficiency9 (18)Congestive heart failure5 (10)History of coronary artery disease (≥2 vessels)13 (16)History of angina11 (22)Abnormal stress test4 (8)Myocardial infarction >72 hours and <6 weeks prior to surgery2 (4)Severe chromic obstructive pulmonary disease7 (14)Uncontrolled diabetes2 (4) Open table in a new tab Table IIComparison of patients with stroke/transient ischemic attack (TIA) after transcarotid arterial revascularization (TCAR) + intravascular lithotripsy (IVL)Stroke/TIA (n = 4), No. (%)Nonstroke/TIA (n = 45), No. (%)P valueSymptomatic carotid disease2 (50)18 (40).70Preoperative stenosis (%)9386.35Chronic renal insufficiency3 (75)9 (20).01Congestive heart failure1 (25)12 (27).94Coronary artery disease3 (75)36 (80).81Hypertension4 (100)42 (93).60Prior coronary intervention3 (75)26 (58).50Arrhythmia1 (25)14 (31).80Chronic obstructive pulmonary disease1 (25)8 (18).72Diabetes1 (25)12 (27).94General anesthesia2 (50)39 (87).05Circumferential calcium2 (50)26 (58).76Eccentric calcium1 (25)19 (42).50Calcium thickness, mm33.6.99Mean flow reversal time, minutes2426.98Mean procedure time, minutes8890.64Pre-IVL angioplasty2 (50)18 (40).70Post-IVL angioplasty2 (50)17 (38).63Poststent angioplasty2 (50)19 (42).76 Open table in a new tab" @default.
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• W4377261985 date "2023-06-01" @default.
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• W4377261985 title "Multicenter Experience With Intravascular Lithotripsy for Treatment of Severe Calcification During TCAR for High-risk Patients" @default.
• W4377261985 doi "https://doi.org/10.1016/j.jvs.2023.03.053" @default.
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