• CLINICAL VIGNETTE

Revascularization technique with use of lithotripsy of intracranial calcified critical stenosis of the internal carotid artery

Paweł Latacz1, Krzysztof Kwiecień1, Marian Simka2

1Department of Vascular Surgery and Angiology, Brothers of Mercy St. John of God Hospital, Kraków, Poland

2Department of Anatomy, University of Opole, Opole, Poland

Intravascular lithotripsy (IL) is increasingly becoming a useful method for endovascular management of calcified plaques in different arterial territories (coronary, renal, mesenteric, extremity, and extracranial carotid arteries), especially, if such stenoses cannot be addressed using cutting balloons or transcatheter atherectomy devices [1–4]. This case report demonstrates a successful application of IL of a highly calcified lesion in the cavernous (C4) segment of the right internal carotid artery (ICA) in a 62-year-old symptomatic female patient presenting with transient ischemic attack and a 2-month history of right-hemisphere stroke. Computed tomography angiography (CTA) revealed 60% stenosis in the brachiocephalic trunk, 30% stenosis in the cervical (C1) segment, and a critically stenosed calcified cavernous (C4) segment of the right ICA. Since standard management of this lesion was associated with high risk of unsuccessful revascularization, which, in turn, could result in complete occlusion and life-threatening stroke, we decided to address it using IL.

The overall endovascular strategy was explained to the patient, and she gave informed consent. Catheter angiography demonstrated good inflow to the left cerebral hemisphere but no collateral inflow to the right side. On the right side, our findings were in line with CTA (Figure 1A).

Firstly, a guidewire was navigated into the M1 segment of the middle cerebral artery. The stenosis in the C4 segment of ICA was predilated using balloons under the pressure of 8–16 atm. Such a pressure, which was much higher in comparison with standard angioplasty for intracranial lesions, was used because the target lesion was highly calcified. Then, we introduced a 3.5/12 mm Shockwave C2 (Shockwave Medical, Santa Clara, CA, US) intravascular lithotripsy catheter (Figure 1B). At the level of calcified plaque, we inflated a balloon of this system under the pressure of 2–4 atm. and performed 2, then 4, and again 4 applications of sonic energy; then the lesion was dilated with the balloon under the pressure of 6–12 atm. Since the stenosis was recoiling (Figure 1C), we advanced an aspiration catheter up to the lesion, and through this catheter implanted a 3.5/12 mm Xience Sierra drug-eluting stent (Abbott, Chicago, IL, US) (Figure 1D). This stent is characterized by a higher radial force than typical stents used to address intracranial lesions. Still, there was a considerable risk of recoil, which could not be reopened if a standard radial force stent was used. Besides, this stent has a low profile, which facilitated its navigation to the intracranial part of the ICA. The final angiographic result of the procedure was good (residual stenosis <10%) with correct inflow to the arteries of the right hemisphere (Figure 1E). The postprocedural course (6 months) was uneventful. CTA performed 8 weeks after the procedure did not show re-stenosis (Figure 1F).

Although the procedure was successful, it should be noted that the first two applications of sonic energy were poorly tolerated by the patient; she experienced extremely high noise during lithotripsy. Therefore, further applications were performed under analgosedation. We demonstrated that intravascular lithotripsy of a highly calcified critical stenosis in the intracranial part of the ICA is feasible. However, for the time being, the safety profile of such procedures remains uncertain.

Article information

Conflict of interest: None declared.

Funding: None.

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