Peripheral intravascular lithotripsy in transcatheter aortic valve implantation: a case report

The presence of severe calcific atherosclerosis at the iliofemoral axis may preclude transcatheter aortic valve replacement (TAVR) by the transfemoral (TF) approach. Intravascular lithotripsy (IVL) is a novel technology that fractures intimal/medial calcium, increasing vessel compliance and enabling TF-TAVR in selected patients with peripheral artery disease.

A 76-year-old female presented with severe degenerative calcific aortic valvular stenosis. The patient was planned for TAVR due to high surgical risk status. However, computed tomography analysis revealed significant aortoiliac calcific narrowing, which limited TF access. Intravascular lithotripsy was performed to modify the calcific stenosis in the aortoiliac region, after which TAVR was successfully completed via the transfemoral route. This intervention was crucial in allowing TAVR to be performed at a low risk. The procedure was successful, and the patient was doing well at 8-month follow-up.

Peripheral IVL appears to be a safe and effective solution for TAVR candidates with co-existing iliofemoral calcifications. Using peripheral IVL to facilitate TF access should be part of the TAVR algorithm, to maintain the safety profile and superior outcomes of traditional TF-TAVR. More research is needed to improve the understanding of anatomical selection for IVL in TAVR candidates. Operators performing IVL-assisted TF-TAVR should be familiar with endovascular interventions and bailout solutions, not so much to treat IVL-treated lesions, but to be able to treat any vascular complication that may occur at the puncture site.