Intravascular Lithotripsy and the Need for Scaffolding in Isolated Popliteal Lesions

To assess the feasibility, safety, and midterm outcomes of intravascular lithotripsy (IVL) in isolated heavily calcified lesions (HCLs) of the popliteal artery, a location historically regarded as a "no-stent zone".

This retrospective monocentric cohort included 18 consecutive adult patients where IVL was used to treat a symptomatic isolated popliteal HCL-between November 2021 and September 2025. IVL was followed by interwoven stent implantation in case of residual stenosis ≥30%. In other cases, a drug-coated balloon was used. Technical success, primary and assisted patency, target lesion revascularization, and major adverse limb events (MALE) were recorded. Kaplan-Meier survival analysis was provided for patency and reintervention outcomes.

Indication was a chronic limb-threatening ischemia in 39% of the cases. The median lesion length was 60 mm (interquartile range [IQR]: 55-100), and 39% were chronic total occlusions. The median degree of stenosis was 90% (IQR: 90-100). The median luminal gain achieved post-IVL was 60%. Bailout stenting was required in 39% of the cases. The technical success rate was 100%. Primary patency was 93% at 12 months and 73% at 24 months. During follow-up, MALE occurred in 22%, including 3 reinterventions that all occurred in patients treated without stenting. At last follow-up, 56% of the patients had received a stent in the target lesion.

IVL is an effective and safe vessel preparation tool for isolated popliteal HCLs. Since most patients ultimately require stenting the benefit of IVL in a "nothing left behind" strategy remains questionable.