Intravascular Lithotripsy of Underexpanded and Recoiled Freshly Implanted Internal Carotid Stents

Severe arterial calcification can make balloon and stent expansion challenging. Additionally, the severely calcified lesions are more likely to undergo recoil after successful balloon expansion and even after stenting leading to stent recoil. We report use of Intravascular Lithotripsy (IVL) in the internal carotid artery (ICA). IVL has only rarely been tried in ICA territory. ICA endovascular intervention is unique due to high risk of stroke and distal protection is mandatory to qualify for procedure re-imbursement. IVL is not approved in the ICA territory and not approved for treating underexpanded or recoiled old or new stents. But, calcium debulking devices like Rotational or orbital atherectomy are dangerous in ICA territory while calcium scoring devices might fail. IVL can modify calcified plaque without direct mechanism for embolization. IVL was tried in a long severely calcified lesion that was hard to dilate, had lesion recoil leading to stent recoil and therefore had two layers of underexpanded stents on angiography. The lesion improved from 90% to 10% residual stenosis with IVL treatment. The severe stent recoil was eliminated after IVL leading to good stent expansion throughout the long length of the lesion. This is the first application of IVL in two layers of fresh carotid self-expanding stents. IVL both successfully dilated the underexpanded stents and stopped the repeated stent recoil due to modification of the calcified plaque. This is the first report of IVL used to treat underexpansion as well recoil of two layers of fresh self-expanding stents.