Author + information
- Received October 14, 2018
- Revision received November 19, 2018
- Accepted November 27, 2018
- Published online March 4, 2019.
- Ignacio Cruz-González, MD, PhD,
- Rocío González Ferreiro, MD∗ (, )
- Javier Martín Moreiras, MD, PhD,
- Blanca Trejo Velasco, MD,
- Manuel Barreiro Pérez, MD, PhD,
- Alejandro Diego Nieto, MD, PhD,
- Jesús Herrero Garibi, MD, PhD,
- Javier Rodríguez Collado, MD and
- Pedro Luis Sánchez Fernández, MD, PhD
- Servicio de Cardiología, Hospital Universitario de Salamanca, Instituto de Investigación Biomédica de Salamanca, Facultad de Medicina, Universidad de Salamanca, y CIBERCV, Salamanca, Spain
- ↵∗Address for correspondence:
Dr. Rocío González Ferreiro, Instituto de Investigación Biomédica de Salamanca, Paseo de San Vicente, 58-182, 37007 Salamanca, Spain.
We present the case of an 80-year-old man who presented with symptomatic severe aortic stenosis and coronary artery disease (proximal left anterior descending artery, proximal circumflex artery, and first marginal branch). Surgical risk was considered high (Society of Thoracic Surgeons score 8.3%), so the decision was made to perform percutaneous revascularization and transcatheter aortic valve replacement (TAVR). A pre-procedural computed tomographic scan showed severe calcified peripheral artery disease that involved the iliofemoral arteries, with a minimum diameter of 4.8 mm at the level of the left common femoral artery and 5 mm at the level of the right external iliac artery (Figure 1, Online Video 1). Peripheral arterial disease also affected the subclavian and carotid arteries, which had severe atheromatosis and did not have the minimum diameter required for TAVR. The patient refused transapical and transcaval approaches because these procedures require general anesthesia, so we evaluated the possibility of transfemoral access facilitated by the Shockwave Lithoplasty balloon (Shockwave Medical).
The Shockwave Lithoplasty balloon (Figure 2) is a system that enables treatment of calcified stenoses of the peripheral arteries by lithotripsy (sonic pressure waves). The objective of this system is calcified plaque modification to improve vessel compliance, by the administration of lithotripsy waves that disrupt superficial and deep calcium with a minimal impact on healthy tissue.
The optimal right common femoral artery puncture site was identified by ultrasound guidance. A 6 × 60 mm Shockwave Lithoplasty balloon catheter was advanced to the right external iliac artery over a 0.014-inch wire. The balloon was inflated up to 4 atm (lithotripsy delivery pressure), and the connector was activated to initiate the lithotripsy pulses. A cycle (30 pulses) was delivered at the level of the iliac stenosis, and the procedure was repeated 4 times from the iliac artery to the common femoral artery, maintaining a minimum of 1 cm catheter overlap. After each cycle, the balloon was inflated at nominal pressure (6 atm) (Figure 3, Online Videos 2, 3, and 4). Once Shockwave Lithoplasty balloon dilatation was performed, a large sheath (20 F) was inserted through the iliofemoral vessels without complications. TAVR was performed successfully using a 34-mm CoreValve® Evolut R (Medtronic). Vascular access was sutured using a Prostar XL (Abbott Vascular). Finally, contralateral angiography ruled out vascular complications after the procedure (Figure 4, Online Videos 5, 6, and 7).
To the best of our knowledge, use of the Shockwave balloon to facilitate transfemoral TAVR has not been described before. This system treats specifically superficial and deep calcium with minimal impact on healthy tissue; therefore, it reduces the chances of vessel dissection or rupture. Lithoplasty has been shown to be an effective and safe system for the treatment of moderate and severely calcified femoropopliteal arteries, even in chronic total occlusions (1). The results showed a significant reduction in stenosis severity with high acute gain, no major adverse events, and low rates of stent implantation and target injury revascularization at follow-up. Hence, transfemoral access facilitated by the Shockwave Lithoplasty balloon can be considered in patients with severe calcified peripheral artery disease, after an individual and careful assessment.
The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received October 14, 2018.
- Revision received November 19, 2018.
- Accepted November 27, 2018.
- 2019 American College of Cardiology Foundation