{
    "abstract": "Transcarotid artery revascularization (TCAR) offers a safe alternative to carotid endarterectomy (CEA), but severe calcification is currently considered a contraindication in carotid artery stenting. This study aims to describe the safety and effectiveness of TCAR with intravascular lithotripsy (IVL) in patients with traditionally prohibitive calcific disease.\nAll consecutive patients who underwent TCAR+IVL from 2018-2022 at nine institutions were identified. IVL was combined with pre-dilatation angioplasty to treat calcified vessels before stent deployment. The primary outcome was a new ipsilateral stroke within 30\u00a0days. Secondary outcomes included any new ipsilateral neurologic event (stroke/transient ischemic attack [TIA]) at 30\u00a0days, technical success, and\u00a0<30% residual stenosis.\nFifty-eight patients (62% male; mean age, 78\u00a0\u00b1 6.6\u00a0years) underwent TCAR+IVL, with 22 (38%) for symptomatic disease. Fifty-seven patients (98%) met high-risk anatomical or physiologic criteria for CEA. Forty-seven patients had severely calcific lesions. Fourteen patients (30%) had isolated eccentric plaque, 20 patients (43%) had isolated circumferential plaque, and 13 (27%) had eccentric and circumferential calcification. Mean procedure and flow reversal times were 87\u00a0\u00b1 27 minutes and 25\u00a0\u00b1 14\u00a0minutes. The median number of lithotripsy pulses per case was 90 (range, 30-330), and mean contrast usage was 29\u00a0mL. No patients had electroencephalogram changes or new deficits observed intraoperatively. Technical success was achieved in 100% of cases, with 98% having\u00a0<30% residual stenosis on completion angiography. One patient had an in-hospital post-procedural stroke (1.72%). Four patients total had any new ipsilateral neurologic event (stroke/TIA) within 30\u00a0days for an overall rate of 6.8%. One TIA and one stroke occurred during the index hospitalization, and two TIAs occurred after discharge. Preoperative mean stenosis in patients with any postoperative neurologic event was 93% (vs 86% in non-stroke/TIA patients; P\u00a0= .32), and chronic renal insufficiency was higher in patients who had a new neurologic event (75% vs 17%; P\u00a0= .005). No differences were observed in calcium, procedural, or patient characteristics between the two groups. The mean follow-up was 132\u00a0days (range, 19-520 days). Three stents developed recurrent stenosis (5%) on follow-up duplex; the remainder were patent without issue. There were no reported interventions for recurrent stenosis during the study period.\nIVL sufficiently remodels calcified carotid arteries to facilitate TCAR effectively in patients with traditionally prohibitive calcific disease. One patient (1.7%) suffered a stroke within 30\u00a0days, although four patients (6.8%) sustained any new neurological event (stroke/TIA). These results raise concerns about the risks of TCAR+IVL and whether it is an appropriate strategy for patients who could potentially undergo CEA.",
    "authors": [
        {
            "affiliation": "University of California, Davis Medical Center, Sacramento, CA. Electronic address: kldilosa@ucdavis.edu.",
            "firstname": "Kathryn",
            "initials": "K",
            "lastname": "DiLosa"
        },
        {
            "affiliation": "Cedars-Sinai Medical Center, Los Angeles, CA.",
            "firstname": "Sally",
            "initials": "S",
            "lastname": "Schonefeld"
        },
        {
            "affiliation": "University of California, San Francisco Medical Center, San Francisco, CA.",
            "firstname": "Rym",
            "initials": "R",
            "lastname": "El-Khoury"
        },
        {
            "affiliation": "University of California, San Francisco Medical Center, San Francisco, CA.",
            "firstname": "Charles",
            "initials": "C",
            "lastname": "Eichler"
        },
        {
            "affiliation": "Keck School of Medicine of University of Southern California, Los Angeles, CA.",
            "firstname": "Alexander",
            "initials": "A",
            "lastname": "DiBartolomeo"
        },
        {
            "affiliation": "Keck School of Medicine of University of Southern California, Los Angeles, CA.",
            "firstname": "Gregory A",
            "initials": "GA",
            "lastname": "Magee"
        },
        {
            "affiliation": "University of Colorado Anschutz School of Medicine, Aurora, CO.",
            "firstname": "Jeniann",
            "initials": "J",
            "lastname": "Yi"
        },
        {
            "affiliation": "University of Colorado Anschutz School of Medicine, Aurora, CO.",
            "firstname": "Andrea",
            "initials": "A",
            "lastname": "Simioni"
        },
        {
            "affiliation": "Baylor Scott and White Heart Hospital Plano, Plano, TX.",
            "firstname": "Dennis",
            "initials": "D",
            "lastname": "Gable"
        },
        {
            "affiliation": "Mount Sinai Medical Center, Miami Beach, FL.",
            "firstname": "Robert",
            "initials": "R",
            "lastname": "Barghout"
        },
        {
            "affiliation": "Mount Sinai Medical Center, Miami Beach, FL.",
            "firstname": "Micheal",
            "initials": "M",
            "lastname": "Ayad"
        },
        {
            "affiliation": "McLaren Health, Bay City, MI.",
            "firstname": "Nicolas J",
            "initials": "NJ",
            "lastname": "Mouawad"
        },
        {
            "affiliation": "University of California, Davis Medical Center, Sacramento, CA.",
            "firstname": "Steven",
            "initials": "S",
            "lastname": "Maximus"
        },
        {
            "affiliation": "Cedars-Sinai Medical Center, Los Angeles, CA.",
            "firstname": "Donald",
            "initials": "D",
            "lastname": "Baril"
        },
        {
            "affiliation": "Maine Medical Center, Portland, ME.",
            "firstname": "Nathan",
            "initials": "N",
            "lastname": "Aranson"
        },
        {
            "affiliation": "Cedars-Sinai Medical Center, Los Angeles, CA.",
            "firstname": "Ali",
            "initials": "A",
            "lastname": "Azizzadeh"
        },
        {
            "affiliation": "University of California, Davis Medical Center, Sacramento, CA.",
            "firstname": "Misty",
            "initials": "M",
            "lastname": "Humphries"
        }
    ],
    "conclusions": null,
    "copyrights": "Copyright \u00a9 2024 The Authors. Published by Elsevier Inc. All rights reserved.",
    "doi": "10.1016/j.jvs.2024.04.049",
    "journal": "Journal of vascular surgery",
    "keywords": [
        "Carotid disease",
        "Cerebrovascular",
        "Lithotripsy"
    ],
    "methods": null,
    "publication_date": "2024-05-23",
    "pubmed_id": "38777157",
    "results": "Fifty-eight patients (62% male; mean age, 78\u00a0\u00b1 6.6\u00a0years) underwent TCAR+IVL, with 22 (38%) for symptomatic disease. Fifty-seven patients (98%) met high-risk anatomical or physiologic criteria for CEA. Forty-seven patients had severely calcific lesions. Fourteen patients (30%) had isolated eccentric plaque, 20 patients (43%) had isolated circumferential plaque, and 13 (27%) had eccentric and circumferential calcification. Mean procedure and flow reversal times were 87\u00a0\u00b1 27 minutes and 25\u00a0\u00b1 14\u00a0minutes. The median number of lithotripsy pulses per case was 90 (range, 30-330), and mean contrast usage was 29\u00a0mL. No patients had electroencephalogram changes or new deficits observed intraoperatively. Technical success was achieved in 100% of cases, with 98% having\u00a0<30% residual stenosis on completion angiography. One patient had an in-hospital post-procedural stroke (1.72%). Four patients total had any new ipsilateral neurologic event (stroke/TIA) within 30\u00a0days for an overall rate of 6.8%. One TIA and one stroke occurred during the index hospitalization, and two TIAs occurred after discharge. Preoperative mean stenosis in patients with any postoperative neurologic event was 93% (vs 86% in non-stroke/TIA patients; P\u00a0= .32), and chronic renal insufficiency was higher in patients who had a new neurologic event (75% vs 17%; P\u00a0= .005). No differences were observed in calcium, procedural, or patient characteristics between the two groups. The mean follow-up was 132\u00a0days (range, 19-520 days). Three stents developed recurrent stenosis (5%) on follow-up duplex; the remainder were patent without issue. There were no reported interventions for recurrent stenosis during the study period.",
    "title": "Multi-center experience with intravascular lithotripsy for treatment of severe calcification during transcarotid artery revascularization for high-risk patients.",
    "xml": "<Element 'PubmedArticle' at 0x788504ccfab0>"
}