Intravascular lithotripsy prior to transcarotid arterial revascularization: A technical tale of two cases

calcific carotid stenosis is becoming more common as the advanced-age population grows, requiring new therapeutic approaches. As such, transcarotid arterial revascularization is gaining significant popularity in the management of carotid stenosis due to low rates of perioperative complications and optimal clinical outcomes. In addition, intravascular lithotripsy has shown promise in safely facilitating the success of endovascular procedures in the context of calcified lesions. The combination of neuroprotective technology offered by transcarotid arterial revascularization and circumferential plaque remodeling by intravascular lithotripsy has been utilized for complex lesions. We present two cases of symptomatic calcific carotid stenosis treated with intravascular lithotripsy before transcarotid arterial revascularization. A 4 × 40 mm lithotripsy balloon delivered shockwaves at two and four atmospheres over a 0.014 wire. Transcarotid arterial revascularization was successfully completed without complications, and luminal patency was observed in both patients. Calcific carotid stenosis was effectively treated with intravascular lithotripsy before transcarotid arterial revascularization, resulting in optimal safety and clinical recovery. Thus, when combined with novel shockwave technology, the neuroprotective effect of flow reversal in transcarotid arterial revascularization procedures demonstrates promise in maintaining safety while providing a novel treatment technique for high-risk patients with calcific cervical internal carotid artery stenosis.