All what you want to learn about shock wave lithotripsy

1. The new kid on the block
Intravascular Lithotripsy
Ahmed Elborae, M.D, Ph.D, MRCP (UK), EAPCI certified
Lecturer of Cardiology, Cairo University

2. Agenda
• IVL concept
• How to perform?
• When?
• Rota or IVL?
• Practical algorithm

3. Rota unmet need…
• Technically demanding
• Extra procedural steps
• Learning curve (20-30 cases)…..
• Deep calcium ?

4. IVL concept
• Same idea of renal stone ESWL therapy
• EU approval 2017, FDA approval 2021 for coronary use
• Make use of balloon system (Ultrasonic emitters)
• Receive electric discharge from the generator > vaporizes the fluid inside >
micro bubbles> High-speed sonic shock waves (equivalent to 50 atm) >
Density proportional effect >intimal and medial Ca fractures
Hennessey B, et al. Open Heart 2023;10:e002182.

5. IVL components (3)
• Generator
• Connecter cable (Therapy button)
• IVL Rx catheter

6. IVL components (3)
• Generator
• Connecter cable (Therapy button)
• IVL Rx catheter

7. IVL components (3)
• Generator
• Connecter cable (Therapy button)
• IVL Rx catheter
Covered by Sterile sleeve

8. IVL Rx catheter
• Compatible with 6F guide
• All 12 mm length
• Available diameters
(2.5-3.0-3.5-4.0 mm)
• Use 1:1 sizing ratio

9. Agenda
• IVL concept
• How to perform?
• When?
• Rota or IVL?
• Practical algorithm

10. Simple as this!
If you can do balloon angioplasty
You can do it !

12. No air!

13. (8 cycles, each cycle= 10 pulses, total = 80)
Generator is programmed to stop for 10 seconds after each cycle
Recommended cycles: At least 2 cycles/segment
*New C2+ system provides 120 pulses

15. Agenda
• IVL concept
• How to perform?
• When?
• Rota or IVL?
• Practical algorithm

16. When to use?
Percutaneous interventional cardiovascular medicine – The PCR-EAPCI Textbook
OCT score >3
IVUS score ≥ 2
Native heavily calcified lesion
? = Predictors of stent under-expansion

17. When to use?
• Stent failure (Under-expanded stent in calcified vessel) > SMILE , CRUNCH
registries (Procedural success 92%)
• Avoid use in freshly implanted stents (Potential damage to the polymer)
Percutaneous interventional cardiovascular medicine – The PCR-EAPCI Textbook

18. A 67-year-old female patient, CC III
360° ARC
40 mm Length

19. 3.5 x 12 mm shockwave C2 IVL balloon
After 10 pulses After 20 pulses

20. Calcium fractures
Before IVL
After IVL

21. Rota or IVL?

22. Rota
Superficial Ca
Diff. abrasions
IVL
+Deep Ca
fractures

23. Calcified lesions are not the same…
doi.org/10.3389/fcvm.2023.1133510

24. Eccentric calcification need more pulses !
Eccentric Vs. concentric calcification ?
Less

25. IVL favored
• Large vessels
• Thick calcium >0.5 mm
• Bifurcations (Keep wire)
• Tortuosity & angulation
Rota-ablation favored
• Small vessel < 2.5 mm
• Diffuse long lesions >50 mm
• Nodular calcification
• Balloon uncrossable & CTO

26. doi.org/10.1016/j.jacasi.2022.11.016

27. Shocktopics !
Disrupt CAD III : IVL-induced capture was noted in 41.1% (Mechanical energy)
Did not result in sustained ventricular arrhythmias
Especially in patients with low heart rate < 60 Bpm

28. Evidence behind

29. Rota-shock trial.Catheter Cardiovasc Interv. 2023;102:823–833.
ROTA-shock trial
IVL is non‐inferior to RA regarding MSA; with no significant
differences in periprocedural myocardial damage

30. Rotatripsy concept !
• Balloon un-dilatable lesion after Rota > Lithotripsy
• Balloon un-crossable extremely calcified (Superficial +deep) >
Tunneling with Rota + cracking with lithotripsy
J INVASIVE CARDIOL 2023;35(2):E70-E74. Epub 2023 January 6.

31. Agenda
• IVL concept
• How to perform?
• When?
• Rota or IVL?
• Practical algorithm

32. Hennessey B, et al. Open Heart 2023;10:e002182.
Practical algorithm
If intracoronary imaging available

33. EAPCI consensus 2023.academic.oup.com/eurheartj/article/44/41/4340/7174174
Practical algorithm
If no intracoronary imaging available

34. Thank you !