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 le-sions 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 expan-sion before and after PIVL treatment were evaluated in surgically isolated, perfused atherosclerotic lower-leg ar-teries and in perfused whole cadaveric lower legs. Analytical methods included micro-computed tomography (mu CT), 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 degrees 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. Ves-sels within whole-leg specimens also showed full-thickness fracturing and a mean of 1.9 1 0.9 mm in acute lu-minal gain, 101.6 1 99.5 % gain in total minimum cross-sectional area, and a 31.7 1 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 ec-centric calcium lesions, and resulted in acute luminal gain. A clinical feasibility study of PIVL is currently enrolling. (c) 2023 The Authors. Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).