Advances in intravascular lithotripsy: mechanisms, devices, and clinical applications.

Introduction: Peripheral arterial disease (PAD) complicates endovascular interventions due to vascular calcifications, which compromise procedural success and long-term outcomes. Intravascular lithotripsy (IVL) represents a promising innovation to modify calcified lesions with shockwaves, addressing unmet clinical needs.

Areas covered: This review explores the mechanisms, devices, and clinical applications of IVL in PAD treatment. It highlights the limitations of conventional approaches (high-pressure balloons, specialty balloons, atherectomy), which often result in suboptimal lesion preparation and procedural complications. Particular emphasis is placed on the combination of atherectomy and IVL, as well as the various IVL devices available and in development, beyond those from Shockwave Medical. Additionally, we discuss future perspectives, including drug penetration enhancement and the issue of post-IVL recoil. Additionally, the literature review methodology, encompassing searches in PubMed and Embase, from January 2008 to December 2023, is briefly outlined.

Expert opinion: IVL offers a safe, effective, and innovative approach to treating calcified lesions while preserving surrounding tissues. However, the current evidence, mainly derived from industry-funded studies, is limited by heterogeneous calcification classifications and a lack of long-term outcome data. Independent research is essential to define IVL's role in PAD treatment algorithms, especially regarding its cost-effectiveness and long-term primary patency outcomes.