March 2021

The Shockwave Medical M5+ new peripheral intravascular lithotripsy (IVL) catheter cuts procedures times in half and was showed for the first time at the American College of Cardiology (ACC) 2022 meeting. It is designed to break up calcium in heavily calcified arteries to avoid the need for vessel trauma caused by high pressure angioplasty.

Can a disruptive technology from the past become the nemesis of calcified lesions in the future?

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Throughout its nearly 30-year history, atherectomy has remained something of an under-achiever. Witness a 2020 study in Circulation: Cardiovascular Interventions, where Ajay Kirtane, MD, SM, of Columbia University Medical Center, and co-authors found that adjunctive coronary atherectomy was performed in just 3 percent of the nearly four million cases drawn from the CathPCI Registry in the fourth quarter of 2016, up from 1.1 percent in the third quarter of 2009. 

A comparison of before and after angiography images (top) and optical coherence imaging (OCT - below) showing the impact of intravascular lithotripsy (IVL) in coronary arteries in the DISRUPT CAD III trial. 

Rather than a binary choice—atherectomy or lithotripsy—the market for treating severely calcified lesions seems likely to evolve into a mixture of both technologies. That, in fact, is already occurring. One strategy gaining currency among interventionalists, particularly those in Europe, is to try a high-pressure balloon first in cases of moderately severe calcification and, if the device fails to fully expand, re-enter the vessel with atherectomy. 

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March 2021 Cover