Challenging the No-Stent Zone: Intravascular Lithotripsy for Common Femoral Artery Disease

Background/Objectives: Calcified atherosclerotic disease of the common femoral artery (CFA) is a unique therapeutic challenge. Although endarterectomy has been the gold standard for CFA disease treatment, the evolution of endovascular techniques has led to increasing interest in minimally invasive alternatives to open surgery. Intravascular lithotripsy (IVL) offers calcium modification, facilitating vessel compliance and enhancing the effect of adjunctive therapies. Methods: A systematic review of current literature was conducted to summarize data on clinical outcomes and perioperative complications of IVL for the treatment of calcified CFA disease. Eligible studies up to July 2025 were included. Demographics, procedural and follow-up data were extracted and analyzed. Results: A total of 304 patients across 9 studies were included. The majority of the patients were males (68%) with hypertension (88%), dyslipidemia (75%) and smoking history (65%). Of the included patients, 56% had chronic limb-threatening ischemia (CLTI), with a previous intervention reported in about one-third of them. Additional calcium-modifying technology was used at the discretion of the operator in 11% of cases. The overall dissection rate was 2% (95% confidence interval (CI): 0-6%) with only five cases having flow-limiting dissections. Stenting rate was 3% (95% CI: 0-11%). No perforations or distal embolization events were reported by the rest of the studies apart from one study that had one such case. The overall periprocedural complication rate was 5% (95% CI: 0-13%). The 12-month target lesion revascularization (TLR) rate was 9% (95% CI: 3-18%). Conclusions: IVL could be a safe alternative endovascular option to open repair for treating calcified CFA disease with low rates of procedural complications. Further studies are needed to clarify IVL's role in clinical practice, particularly for patients who are poor candidates for open surgery.