Atherectomy, Case Review, Shockwave, Protected PCI
Shockwave Assisted Protected PCI with Brian Kolski, MD
Brian Kolski, MD, presents a case in which he used the Shockwave Medical Intravascular Lithotripsy (IVL) System to dilate calcified lesions in a 58-year-old patient initially turned down for revascularization options as well as transplant. Dr. Brian Kolski is a cardiologist at St. Joseph Hospital in Orange County, California.
Dr. Kolski explains that the Shockwave intravascular lithotripsy balloon, which is similar to a standard peripheral angioplasty balloon, has high energy emitters that push soundwaves through arterial walls to help break up calcium. In this case, Dr. Kolski used Shockwave with support from the Impella® heart pump to perform atherectomy in a patient with heavily calcified multivessel disease who had been deemed to have insufficient viable territory for revascularization. The patient also had symptoms of bilateral leg claudication and angiography revealed hostile peripheral vasculature due to heavy, dense calcification throughout the bilateral external iliacs and common iliacs.
Anticipating the need for mechanical support, but not knowing which side they would use for Impella, Dr. Kolski and his team used a 7.0x60mm Shockwave balloon in both the right and left sides to improve flow. After inserting Impella, he used CSI Diamondback 360® atherectomy in multiple vessels with excellent luminal gain. “We’ve done a number of the Shockwave cases,” he explains, “and in none of the cases have we required bailout stenting, because generally it is a very atraumatic therapy.” In a young patient such as this, he notes that this leaves more options for future procedures if needed.
The patient was discharged Day 3. At 4-week follow up he had an EF of 45% (up from 20% at initial presentation) and claudication had significantly improved.
"For hostile iliac peripheral access, Shockwave has become our go-to in the algorithm for large bore delivery of therapies,” Dr. Kolski emphasizes. When asked if he was concerned about embolization in a patient with this much calcium, Dr. Kolski replies that part of the advantage of the lithotripsy is that it treats the calcium that’s embedded in the vessel wall. “We have not seen any signal of distal embolization,” he states, “which is why I think people are finding this an exciting way to treat this type of disease.”
When asked about the use of Shockwave as compared to transcaval or axillary procedures, Dr. Kolski explains that this is an active area of study for his team. “But if we can keep the procedures femoral, it tends to keep them simpler and it tends to be a better default strategy than transcaval or axillary access,” states Dr. Kolski. “It’s a wire and a typical balloon and it’s used in a fashion we’re all more comfortable with,” he explains, noting his impression that Shockwave opens the door to “treating more patients better.”