A new use for IVL: helping cardiologists secure transcarotid access for TAVR
Intravascular lithotripsy (IVL), one of today’s most in-demand healthcare technologies, was designed to break up heavily calcified plaques and help prep a patient’s blood vessels for further treatment.
However, cardiologists in California have identified a new way to use IVL: facilitate transcarotid access for transcatheter aortic valve replacement (TAVR) patients. The group shared its experience in JACC: Case Reports.[1]
“Transcarotid access is an alternative approach for TAVR when transfemoral access is not feasible,” wrote corresponding author Olcay Aksoy, MD, an interventional cardiologist with UCLA Health, and colleagues. “Calcific carotid atherosclerosis may preclude the use of the transcarotid approach. We describe the first reported use of intravascular lithotripsy to facilitate successful transcarotid transcatheter aortic valve replacement through a severely diseased, calcified carotid artery.”
Aksoy et al. performed the TAVR on an 88-year-old male patient who presented with severe shortness of breath. He denied feeling lightheaded, dizzy or experiencing any kind of chest pain. He required a walker to move around, and early signs of edema were observed in his lower extremities.
The patient had a history of coronary artery disease that included a non-ST-segment elevation myocardial infarction treated with percutaneous coronary intervention. He also presented with hypertension, hyperlipidemia, type 2 diabetes, obstructive sleep apnea and chronic kidney disease.
After undergoing an electrocardiogram and transthoracic echocardiogram, the group noted that his left ventricular ejection fraction was 65%, aortic valve peak gradient was 36 mm Hg, mean gradient was 24 mm Hg and stroke volume index was 40 mL/m2.
“It was determined that the patient’s symptoms were due to severe aortic stenosis,” the authors wrote. “The patient was evaluated for surgical aortic valve replacement with a Society of Thoracic Surgeons risk score of 5.39%. He was evaluated for TAVR with a multidisciplinary heart team.”
A CT scan and carotid ultrasound revealed significant disease throughout the patient’s arteries. Significant peripheral artery disease made transfemoral TAVR too challenging, and subclavian artery disease made the team want to avoid using transaxillary access. Transapical access, meanwhile, was deemed too risky due to the “significant distance from the chest wall to the left ventricular apex as well as the overlying ribs.”
It was finally determined that transcarotid access would be used for TAVR, but only after the IVL technology developed by Shockwave Medical, the innovators of this technology, was used to help clear the way.
The procedure was a success, the team revealed, and the patient received a Sapien 3 Ultra TAVR valve from Edwards Lifesciences.
“Our case is the first, to our knowledge, to describe the use of IVL to enable a transcarotid TAVR, and IVL-assisted angioplasty of the carotid artery should be considered in future cases in which TAVR access is challenging,” the authors wrote. “This may allow for greater adoption of the transcarotid approach when the transfemoral approach is not feasible, particularly in North America where the use of the transcarotid approach remains low. This strategy should be considered anytime transfemoral access is contraindicated; however, data remain limited.”
Click here for to read the full breakdown in JACC: Case Reports, an American College of Cardiology journal.
Michael has more than 18 years of experience as a professional writer and editor. He has written at length about cardiology, radiology, artificial intelligence and other key healthcare topics.