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J Vasc Surg Cases Innov Tech
J Vasc Surg Cases Innov Tech
Journal of Vascular Surgery Cases, Innovations and Techniques
2468-4287
Elsevier

S2468-4287(24)00156-4
10.1016/j.jvscit.2024.101572
101572
Vascular Images
I only believe what I see: Cracking the code of calcification
Longchamp Justine MD justine.longchamp@chuv.ch

Trunfio Rafael MD
Deslarzes-Dubuis Céline MD
Department of Vascular Surgery, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, Switzerland
11 7 2024
10 2024
11 7 2024
10 5 10157222 4 2024
2 7 2024
© 2024 The Author(s)
2024
https://creativecommons.org/licenses/by/4.0/ This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).
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pmcIntravascular lithotripsy (IVL) represents an innovative technique for remodeling calcified plaques. This technique has shown promising results in the management of peripheral artery disease.1, 2, 3 This report describes a successful case of IVL-assisted distal bypass.

Case report

A 81-year-old man was referred for incapacitating foot pain associated with toe necrosis (Rutheford 5 stage, Wound, Ischemia, foot Infection stage 4). The duplex ultrasound examination showed femoro-popliteal occlusion, monophasic flow in the anterior tibial artery (ATA), both peroneal and tibial posterior arteries were occluded (GLASS stage III). Laser toe plethysmography showed no oscillation. The computed tomography angiography highlighted highly calcified below-the knee arteries (A). The patient was consented for a composite (contralateral great saphenous vein anastomosed with cryopreserved allograft distally) femoro-ATA bypass and provided consent to this publication. Proximal anastomosis was performed on the common femoral artery. ATA was dissected over 15 cm and was found to be highly calcified, looking like an incompressible pipe. Longitudinal arteriotomy with endarterectomy were performed. Circumferential calcified plaque was not ending on distal ATA. Distal plaque fixation was not feasible even with a calcium-dedicated needle.

We decided to perform ATA IVL to soften the plaque. First, a 0.014 Spartacore (Abbott Vascular, Abbott, IL) wire was inserted a few centimeters trough ATA. Then, a 3 × 40-mm Shockwave S4 (Shockwave Medical, Santa Clara, CA) balloon was placed (B/Cover image) and inflated according to the instructions for use.4 Eight cycles of 20 pulses were performed while moving slightly the balloon to focus the pulses at the distal anastomosis spot. By the end of IVL, the artery was softer macroscopically, and the distal anastomosis was performed using Prolene (Ethicon) 6-0. No anastomosis leak was seen, final angiography was done to evaluate distal anastomosis and run off (C). Therapeutic anticoagulation with heparin was started 4 hours after the surgery together with aspirin. The patient had no more foot pain, and duplex ultrasound examination at postoperative day 4 showed triphasic flow in the ATA (D); the toe-brachial index was 0.71.

Conclusions

To our knowledge, this description of IVL is the first use to help soften the plaque of a highly circumferentially below-the-knee artery, allowing the completion of an anastomosis.

Disclosures

None.

Appendix (online only)

Cover image

The editors and reviewers of this article have no relevant financial relationships to disclose per the Journal policy that requires reviewers to decline review of any manuscript for which they may have a conflict of interest.

Additional material for this article may be found online at www.jvscit.org.

Appendix

Additional material for this article may be found online at www.jvscit.org.
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References

1 Wong C.P. Chan L.P. Au D.M. Chan H.W.C. Chan Y.C. Efficacy and safety of intravascular lithotripsy in lower extremity peripheral artery disease: a systematic review and meta-analysis Eur J Vasc Endovasc Surg 63 2022 446 456 34887206
2 Stavroulakis K. Bisdas T. Torsello G. Tsilimparis N. Damerau S. Argyriou A. Intravascular lithotripsy and drug-coated balloon angioplasty for severely calcified femoropopliteal arterial disease Endovasc Ther 30 2023 106 113
3 Tepe G. Brodmann M. Werner M. Intravascular lithotripsy for peripheral artery calcification: 30-day outcomes from the randomized disrupt PAD III trial JACC Cardiovasc Interv 14 2021 1352 1361 34167675
4 Shockwave Medical Inc Peripheral Intravascular Lithotripsy (IVL) Catheter Instructions for Use (IFU) https://shockwavemedical.com/wp-content/uploads/2019/02/PN-61773-Rev-B-S4-Peripheral-IVL-Catheter-IFU-US_WEBSITE-VERSION.pdf
