Off-label use of intravascular lithotripsy in severely calcified carotid stenosis: a case series and literature review.

Background: Severe extracranial carotid artery stenosis caused by heavily calcified coral reef plaque presents major limitations for endovascular therapy. The thickness and length of the calcification can increase the risk of technical failure, stent recoil, and restenosis. Intravascular lithotripsy (IVL) has been utilized to fragment calcium deposits in the intimal and medial layers of the vessel wall before stenting in the coronary and infra-inguinal arteries, resulting in a more pliable plaque and durable intraluminal gain. Our study is unique as it includes both internal and common carotid artery lesions, incorporates various clinical scenarios-including prior surgical interventions and complex ostial disease-and demonstrates technical success and short-term patency across all patients. It adds valuable data to the emerging body of evidence supporting IVL's off-label use in this context and highlights the need for prospective studies to further assess long-term outcomes. Case Description: In this report, we describe four patients treated with adjunct IVL of the internal or common carotid arteries before trans-carotid artery revascularization (TCAR). All four patients recovered without complications and showed excellent stent expansion and luminal gain. Conclusions: IVL could be a valuable adjunct in the treatment of severely calcified carotid artery stenosis, potentially reducing the risk of technical failure, stent recoil, and restenosis. Additional research is needed to assess the long-term safety and efficacy of IVL in the treatment of severely calcified carotid artery stenosis.