Intravascular Lithotripsy for Calcified Vascular Lesions: Mechanisms, Techniques, Clinical Applications, and Future Directions.

Vascular calcification complicates endovascular intervention by reducing vessel compliance, impairing device delivery and expansion, and increasing the risk of suboptimal procedural outcomes. Intravascular lithotripsy (IVL) has emerged as a calcium-modification strategy that uses acoustic pressure waves to fracture vascular calcium while minimizing injury to surrounding tissue. This paper reviews the mechanisms, procedural applications, clinical evidence, and evolving role of IVL in calcified coronary and peripheral arterial disease. We summarize evidence from pivotal prospective trials, randomized studies, registries, observational cohorts, imaging studies, and expert consensus, with particular emphasis on complex coronary and peripheral applications. IVL has demonstrated high procedural success and a favorable acute safety profile in severely calcified coronary lesions, with randomized evidence also supporting its use in calcified femoropopliteal disease. Expanding observational evidence supports its feasibility in complex coronary subsets, including left main and bifurcation lesions, as well as iliac and common femoral disease. Evidence remains more limited for chronic total occlusions, calcified nodules, stent underexpansion, and infrapopliteal disease. Emerging technologies and applications may further broaden the role of lithotripsy, but randomized comparative studies and longer-term outcome data are needed to define its optimal use.