Intravascular lithotripsy in carotid disease

Transcarotid artery revascularization (TCAR) is a hybrid approach with neuroprotective flow reversal for treating carotid stenosis. Providers are increasingly choosing it for patients, especially those at high risk for carotid endarterectomy (CEA). However, TCAR's efficacy is limited by calcific atherosclerosis, which can hinder stent expansion and increase the risk of perioperative embolization. Intravascular lithotripsy (IVL) is introduced as a promising solution to this issue. Initially developed for coronary and peripheral vascular diseases, IVL uses acoustic pressure waves to fracture calcific plaque, enabling better stent deployment. This work details the procedural steps for IVL in conjunction with TCAR, emphasizing its potential benefits and the adjustments needed due to the off-label use of currently available lithotripsy balloons. While IVL shows promise in addressing calcific atherosclerosis in carotid interventions, further research and development of carotid-specific devices are necessary. There is also the need for additional data on the safety and efficacy of this approach before it can be widely adopted.