Safety and efficacy of coronary intravascular lithotripsy for calcified coronary arteries- a systematic review and meta-analysis

Coronary Intravascular Lithotripsy

Coronary artery calcification is strongly associated with adverse cardiac events and can impede the success of percutaneous coronary intervention (PCI) due to challenges with delivery of equipment and expansion of stents. Current treatment modalities for mitigation of coronary calcification have limitations and inherent risk of complications. Coronary intravascular lithotripsy (IVL) is a novel technique to modify coronary artery calcification via acoustic pressure waves. IVL utilizes an easy-to-use device, which does not require a steep learning curve. Prospective studies have shown this technique to be safe and effective and can be used to adequately modify calcified coronary stenoses in preparation for PCI and stent deployment and optimization. IVL has unique features that can be used alone or as an adjunctive therapy to other available calcium modification tools. As compared to the currently established modalities of calcium modification, IVL has the potential to facilitate successful PCI with fewer serious procedural complications. In this review article, we discuss the importance of coronary artery calcification, the role of IVL, its mechanism, the current clinical data behind its use and future directions. Overall, coronary IVL is a promising technology for the treatment of severely calcified coronary stenoses, with a need for, long-term clinical outcome data of IVL-facilitated PCI.

The efficacy of bariatric surgery on pulmonary function and sleep architecture of patients with obstructive sleep apnea and co-morbid obesity: a systematic review and meta-analysis

Obstructive sleep apnea (OSA) is highly prevalent in patients with morbid obesity. There is a growing interest in the role of bariatric surgery in OSA management. This study aims to evaluate the therapeutic efficacy of bariatric surgery on changes in pulmonary function and sleep architecture. Studies of patients with OSA that underwent bariatric surgery were searched in 4 different databases (PubMed, Cochrane, Web of Science, and Embase) until October 31, 2022. We identified studies evaluating the efficacy of surgical intervention on primary outcomes (body mass index [BMI] and apnea-hypopnea index [AHI]) and secondary outcomes such as forced vital capacity (FVC), forced expiratory volume in the first second (FEV1), FEV1/FVC, oxygen desaturation index (ODI), T90, mean oxygen saturation (SpO2), nadirSpO2, sleep efficiency (SE), N1%, N2%, N3%, rapid eye movement (REM%), arousal index, Epworth sleepiness scale (ESS), neck circumference, waist circumference, and weight. A total of 24 eligible studies were finally chosen. Risk of bias assessed through funnel plots was collected and analyzed via random effects meta-analyses. There were significant reductions in BMI and AHI after bariatric surgery induced weight loss. Accordingly, improvement in FVC, meanSpO2, nadirSpO2, SE, N3%, REM%, and ESS were observed compared with baseline. Patients with OSA also exhibit lower ODI, T90, arousal index, neck circumference, waist circumference, and weight after treatment. Bariatric surgery has beneficial effects on patients with OSA and obesity, particularly with morbid obesity. Surgical weight loss significantly eliminates apnea-hypopnea events, reduces weight, increases oxygen saturation, N3 and REM sleep stage, reduces sleep fragmentation, and improves pulmonary functions with augmented FVC.

Pulsatile intravascular lithotripsy: A novel mechanism for peripheral artery calcium fragmentation and luminal expansion

OBJECTIVE

To assess the feasibility and treatment effect of pulsatile intravascular lithotripsy (PIVL) on calcified lesions in a cadaveric model of peripheral artery disease.

BACKGROUND

PIVL represents a novel potential approach to intravascular lithotripsy for the treatment of vascular calcification.

METHODS

In this preclinical device-feasibility study, technical success, calcium morphology and luminal expansion before and after PIVL treatment were evaluated in surgically isolated, perfused atherosclerotic lower-leg arteries and in perfused whole cadaveric lower legs. Analytical methods included micro-computed tomography (μCT), intravascular optical coherence tomography, digital subtraction angiography, and quantitative coronary analysis.

RESULTS

Treatment delivery was successful in all whole-leg specimens (N = 6; mean age 74.2, 66 % female) and in the 8 excised vessels with diameter appropriate to the PIVL balloon (2 vessels exceeding diameter specifications were excluded). There were no vessel perforations. After PIVL, excised vessels showed extensive evidence of new, full-thickness fractures in lesions with calcium arc exceeding 152° and with calcium wall thickness between 0.24 mm and 1.42 mm. PIVL fractures were observed in intimal nodules, sheets, shingles, and medial plates. Vessels within whole-leg specimens also showed full-thickness fracturing and a mean of 1.9 ± 0.9 mm in acute luminal gain, 101.6 ± 99.5 % gain in total minimum cross-sectional area, and a 31.7 ± 13.4 % relative reduction in stenosis (P < 0.001 for all analyses).

CONCLUSIONS

In a cadaveric model, PIVL treatment was technically feasible, fractured both circumferential and eccentric calcium lesions, and resulted in acute luminal gain. A clinical feasibility study of PIVL is currently enrolling.

Use of Intravascular Lithotripsy in Heavily Calcified Renal Artery Stenosis: A Case Report

Heavily calcified arterial lesions are difficult to treat in an endovascular manner with conventional techniques due to limited arterial compliance. Intravascular lithotripsy offers a novel minimally invasive therapeutic option through endovascular emission of acoustic waves, fracturing calcium deposits and facilitating lesion dilation. We present the case of a successful application of the Shockwave intravascular lithotripsy system (IVL®, Shockwave Medical Inc) in a heavily calcified stenosis of the right renal artery in a patient with a coral reef aorta.

Intravascular lithotripsy for coronary calcium: A case report and review of the literature

BACKGROUND

Coronary calcium poses a challenge for the interventional cardiologist often leading to stent under-expansion and subsequent ischemic events. Aggressive balloon post-dilatation though helpful is usually inadequate. Multiple plaque ablation techniques are in vogue, but they are technically demanding and are not without complications. Shockwave intravascular lithotripsy (S-IVL) has emerged as a user-friendly and effective mechanism for calcium management with a high safety margin. A series of trials (DISRUPT CAD I-IV) have demonstrated both short-term and long-term safety and efficacy of the technique. As experience with the technique grows more and more, therapy areas like stent restenosis are being covered by the S-IVL.

CASE SUMMARY

We report a series of 2 cases successfully managed with S-IVL therapy at our center. The first case is of a 57-year-old smoker who presented with acute coronary syndrome. His left anterior descending coronary artery revealed calcified 90% stenosis on angiogram and a combination of superficial-deep calcium on intracoronary imaging. The calcium was treated with 20 pulses of S-IVL to create discontinuity and a sirolimus eluting drug-eluting stent was successfully implanted. The second case is that of an elderly lady who presented with stable angina and demonstrated diffuse calcified lesions in the left anterior descending artery on angiogram. She also demonstrated a mixture of superficial and deep seated calcium zones on imaging. S-IVL therapy was applied to generate fractures in calcium, and two overlapping drug-eluting stents were implanted successfully without any complications.

CONCLUSION

S-IVL is an emerging, efficient, user-friendly and safe therapy for managing intracoronary calcium in routine interventional practice.

Intravascular Lithotripsy as a Novel Treatment Method for Calcified Unprotected Left Main Diseases-Comparison to Rotational Atherectomy-Short-Term Outcomes

Background: The unprotected calcified Left Main disease represents a high-risk subset for percutaneous coronary intervention (PCI), and it is associated with a higher number of periprocedural complications and an increased rate of in-stent thrombosis and restenosis. Adequate lesion preparation plays a crucial role in achieving a favorable PCI outcome. Rotational Atherectomy (RA) is a well-established plaque-modifying method; nevertheless, the data regarding the effectiveness of RA in LM diseases is scarce. Recently, the novel ShockWave-Intravascular-Lithotripsy(S-IVL) device has been introduced to the PCI armamentarium in order to modify the calcified plaque. Methods: We performed a retrospective evaluation of 44 consecutive subjects who underwent the LM-PCI, and who were supported by either the RA or S-IVL. Results: The Rota group consisted of 29 patients with a mean syntax score of 28.0 ± 7.5. The S-IVL group was composed of 15 subjects with a syntax score of 23.3 ± 13.0 There were no statistical differences regarding MACE between the RA and Shockwave arms of the in-hospital group (10.3% vs. 6.7%), or in the six month (17.2% vs. 13.3%) follow-up group. Conclusions: RA and S-IVL could be safe and effective therapeutic strategies for calcified LM disease. Further studies with a higher number of participants and longer follow-up times are warranted to establish the potential benefits of RA and S-IVL for the management of LM stenosis.

Contemporary Evidence-Based Diagnosis and Management of Severe Coronary Artery Calcification

Percutaneous treatment of heavily calcified coronary lesions remains a challenge for interventional cardiologists with increased risk of incomplete lesion preparation, suboptimal stent deployment, procedural complications, and a higher rate of acute and late stent failure. Adequate lesion preparation through calcium modification is crucial in optimising procedural outcomes. Several calcium modification devices and techniques exist, with rotational atherectomy the predominant treatment for severely calcified lesions. Novel technologies such as intravascular lithotripsy are now available and show promise as a less technical and highly effective approach for calcium modification. Emerging evidence also emphasises the value of detailed characterisation of calcification severity and distribution especially with intracoronary imaging for appropriate device selection and individualised treatment strategy. This review aims to provide an overview of the non-invasive and invasive evaluation of coronary calcification, discuss calcium modification techniques and propose an algorithm for the management of calcified coronary lesions.

Intravascular lithotripsy during percutaneous coronary intervention: current concepts

INTRODUCTION

Coronary artery calcification (CAC) is commonly encountered by interventional cardiologists. Severe CAC may impair stent delivery or result in stent underexpansion, stent thrombosis and/or in-stent restenosis (ISR). Multiple tools have been developed to help overcome the challenges associated with CAC and improve outcomes for these patients. Intravascular shockwave lithotripsy (IVL) is a novel therapy that uses acoustic pressure waves for the modification of CAC.

AREAS COVERED

This review discusses the growing body of evidence to support the safety and efficacy of IVL in the setting of de novo severely calcified coronary arteries prior to stenting. We also discuss international real world experience with the coronary IVL system. This includes the use of IVL in the setting of acute coronary syndrome (ACS), ISR and in combination with other tools for calcium modification.

EXPERT OPINION

IVL is a safe and effective therapy that results in the fracture of coronary calcium and facilitates optimal stent delivery and expansion. Longer term follow up is essential to shed light on the durability and late outcomes of an IVL strategy. Randomised control trials are warranted to compare IVL to alternative methods of calcium modification and to explore further the use of IVL for ACS.

Efficacy and safety of intravascular lithotripsy in calcified coronary lesions: A systematic review and meta-analysis

BACKGROUND

Intravascular lithotripsy (IVL) is a recently introduced therapeutic modality in the management of calcified coronary lesions (CCAD). IVL delivers sonic pressure waves to modulate calcium, hence promote vessel compliance and optimize stent deployment.

METHODS

We performed a comprehensive literature search for studies that evaluated the utility of adjunctive IVL. The primary outcomes of our study were the clinical success, defined as the ability of IVL to produce residual diameter stenosis <50% (RDS < 50%) after stenting with no evidence of in-hospital major adverse cardiac events, and the angiographic success, defined as success in facilitating stent delivery with RDS < 50% and without serious angiographic complications. The secondary outcomes included post-IVL and post-stenting changes in lumen area, calcium angle, and the maximum calcium thickness. Proportional analysis was used for binary data and mean difference was used for continuous data. All meta-analyses were conducted using a random-effect model and 95% confidence intervals (CIs) were included.

RESULTS

A total of eight single-arm observational studies, including 980 patients (1011 lesions), were included. 48.8% of the patients presented with acute coronary syndrome. Severe calcifications were present in 97% of lesions. Clinical success was achieved in 95.4% of patients (95%CI:92.9%-97.9%). Angiographic success was achieved in 97% of patients (95%CI:95%-99%). There was an overall increase in postprocedural lumen area as well as significant reduction of calcium angle and maximum calcium thickness.

CONCLUSIONS

IVL seems to have excellent efficacy and safety in the management of CCAD. However, adequately powered RCTs are needed to evaluate IVL compared to other calcium/plaque modifying techniques.