Purpose: To assess the feasibility and safety of intravascular lithotripsy (IVL) for enabling transfemoral abdominal (EVAR), thoracic (TEVAR), and thoracoabdominal (BEVAR) endovascular aneurysm repair in patients with narrow and calcified iliac arteries. Materials and methods: Consecutive patients treated with IVL for severe calcified and narrowed iliac access before EVAR, TEVAR, or BEVAR between November 2020 and June 2022 were retrospectively evaluated. All anatomical iliac characteristics were acquired by multi-planar reconstruction of preoperative computed tomography angiography (CTA). The hostility of the vascular accesses was classified based on Peripheral Arterial Calcium Scoring System (PACSS) and calcified access severity score (CASS), a new score considering both anatomical (calcium grade and length, minimum lumen diameter [MLD], and tortuosity index) and aortic stent-graft (SG/MLD index) parameters. Primary endpoint was technical success defined as successful aortic endograft delivery and deployment without iliac rupture. Freedom from complications and primary patency were additionally analyzed. Results: Twenty-eight iliac axes were treated with IVL (8 bilateral) in 20 patients (mean age 74.5±6.7 years) with a mean follow-up of 26.5±6.2 (range 17–36) months. Ten patients underwent EVAR: 3 TEVAR, and 7 BEVAR procedures. In 14 patients (70%), aneurysm disease was associated with symptomatic aorto-iliac occlusive disease (AIOD), with Rutherford class III to IV. The PACSS was grade IV in 89% of the cases and the CASS (mean 14±2) was grade III to IV in all cases. The stent-graft (SG) outer diameter (5.60±1.65 mm) was significantly larger by 50% than MLD (3.96±1.20 mm), with an SG/MLD index of 1.50±0.51 (p<0.001). Technical success was 100%. No dissection, rupture, or distal embolization occurred. One (3.4%) bail-out stenting was necessary as endoconduit after IVL treatment. One month CTA showed that postoperative luminal gain increased by 93% (p<0.001). An improvement of 2 Rutherford classes occurred in all AIOD patients with a primary patency of 100% at last follow-up. Conclusions: This study shows the safety and feasibility of IVL as a valuable option to treat narrow and calcified iliac arteries to facilitate endograft delivery. Further studies will be useful to confirm these results. Clinical Impact: In this article, the use of intravascular iliac artery lithotripsy to facilitate aortic endograft delivery is explored. The presence of iliac severe calcifications still represents a contraindication for aortic endovascular repair. Intravascular lithotripsy increases the feasibility and safety of endovascular aortic procedures, facilitating endograft delivery and reducing the risk of iliac rupture and/or dissections by improving vessel compliance and luminal gain. This novel vessel preparation could be an alternative to “paving and cracking” and/or iliac conduits. This study describes a new score to classify the severity of iliac calcifications, considering anatomical parameters and the profile of aortic endografts delivery system.

To evaluate safety and efficacy of intravascular lithotripsy (IVL) treatment in calcified iliac arteries and explore a new approach to determining whether to stent or not to stent calcific iliac vessels. All consecutive patients who underwent IVL (Shockwave Medical) for calcified iliac arteries from February 2021 to May 2024 at 4 centers were included. Indication for IVL was Rutherford category ≥ 3 in iliac lesions with moderate-to-severe calcification and was based on a new algorithm: IVL as stand-alone therapy +/- provisional stenting in case of stenosis, or IVL as vessel preparation for planned stenting in cases of chronic total occlusion (CTO). The primary endpoint was primary patency; assisted primary patency, secondary patency, and freedom from iliac complications were also analysed. Clinical and procedural data were compared between two groups: IVL stand-alone therapy (IVL ONLY) vs. IVL with adjunctive stenting (IVL+STENT). Indication for IVL ONLY was based on adjunctive completion assessments (extravascular ultrasound [EVUS] and translesional gradient pressure). A Cox regression univariate analysis between cases with or without target lesion revascularization (TLR) was performed. In total, 100 iliac arteries were treated in 86 patients (52 male, mean age 74±9 years). Median follow-up was 20 months (range 1-45 months). Critical limb ischemia was present in 55% of the patients, the majority of whom (75%) had severe calcifications (180-360°). The mean target lesion length was 40.95±29.25 mm with a mean stenosis of 84±10% (12 CTO). Technical success was 99%. The target lesions were treated with IVL ONLY in 77% of cases, while IVL+STENT was employed in the remaining 23% of the cases (provisional stenting 11%, planned stenting 12%). Mean residual stenosis was 14.95±14% at final angiogram. EVUS with improved imaging (bi-triphasic in place of monophasic/blunted ipsilateral common femoral artery waveform), and/or decreased translesional gradient pressure (mean: -71%) were detected in all IVL ONLY cases. Primary patency and assisted primary patency at 24 months were 95% (95% CI: 85.1%-98.1%) and 98% (95% CI: 92%-99.5%), respectively, while secondary patency was 100%. Primary patency showed no statistically significant difference (p=24) between IVL ONLY and IVL+STENT groups. There was one iliac rupture and no distal embolization. Longer target lesions (p=024) were significantly related to TLR. Intravascular lithotripsy is a safe and effective treatment option for calcific iliac occlusive disease. This multicenter experience shows promising mid-term results in terms of primary patency despite the very low stenting rate, preserving future treatment options. Further studies are needed to confirm these findings.

Contrast arteriography (CA) is considered the gold standard to evaluate any phase in peripheral arterial disease (PAD) interventions, from diagnostics to final results. Nevertheless, duplex ultrasonography (DUS) mostly used for the pre/postoperative phase and follow-up control, could be a potential intraoperative adjunctive imaging tool to assess the effects of endovascular revascularization in patients with iliac and femoropopliteal lesions. The PAD “duplex-assisted” protocol includes a preoperative DUS control followed by an intraoperative and a postoperative control. The most important parameters are pulsed doppler spectral analysis and waveform changes, which are impossible to detect with intravascular ultrasound (IVUS). By using a similar acronym, the intraoperative DUS has been previously described as extravascular ultrasound (EVUS). B-mode imaging, color flow, and peak systolic velocity (PSV) are considered. EVUS could be very useful to evaluate the effects of endovascular treatment, mainly in cases of unclear CAs, severe calcifications and/or dissections. In the context of the “leaving nothing behind” strategy, EVUS can drive the physician to evaluate the absence of flow-limiting dissections and decide which target lesion should be treated with antirestenotic therapy, further vessel preparation, or stenting. The EVUS protocol could be a safe and feasible option to improve the completion assessment of endovascular PAD treatment. A better ultrasound waveform is a sign of improved luminal gain and compliance, which is extremely important to finalize the results of new peripheral device technology, such as intravascular lithotripsy.

The use of chimney technique in endovascular repair of abdominal aortic aneurysms (ChEVAR) has had a secondary role. Although it was first developed in an emergent/urgent setting, the publication of various important studies has helped overcome scepticism towards this technique in elective procedures. This paper reviews current evidence about ChEVAR, focusing on clinical results, technical notes and comparisons with other techniques. The new ChEVAR findings show favourable mid- and long-term clinical outcomes, even in elective patients. These results, comparable to those related to fenestrated endografts, have been achieved through standardisation in planning and materials. An adequate endograft oversizing associated to the right aortic neck length is fundamental to avoid ChEVAR-related complications, such as type 1a endoleaks. These data indicate that ChEVAR, compared to other complex endovascular treatments, has comparable outcomes along with features that could make it an essential option in every clinical setting.