Intravascular lithotripsy (IVL) is an innovative treatment for artery calcification that has the potential to transform the treatment of coronary artery disease (CAD) and peripheral arterial disease (PAD). So what happens during an IVL procedure? In this article, we break down IVL step-by-step and look at the equipment used during an IVL procedure.

Overview of an IVL Procedure

The purpose of an IVL procedure is to modify the hard, calcified plaque in a person’s arteries in order to optimize stent placement and/or improve blood flow. During an IVL procedure, an intravascular lithotripsy catheter with an integrated angioplasty balloon is inserted into the artery. Emitters within the balloon generate sonic pressure waves, or shock waves, that direct mechanical energy at a targeted lesion (or area of plaque blockage in the arteries). This energy creates cracks and fissures in the hard plaque, while passing harmlessly through soft tissues.

After being exposed to a series of pressure waves, the calcium deposits in the artery begin to crumble. Removing these plaque deposits helps to clear the artery for additional interventional treatments and/or optimal stent placement. By using intravascular imaging techniques during and after the IVL treatment, it’s possible to ensure that the plaque has been thoroughly disrupted.

3 Key Components of an IVL Procedure

IVL is a multi-faceted system that includes a lithotripsy catheter with an integrated angioplasty balloon that is connected to a generator. IVL equipment includes:

• IVL catheter: A single-use, sterile, disposable catheter with an integrated angioplasty balloon.

• Angioplasty balloon: Integrated within the IVL catheter, it contains lithotripsy energy emitters.

• Energy generator: The generator powers the emitters, which generate sonic pressure waves, or shock waves.

A Step-By-Step Look at an IVL Procedure

The treatment procedure for IVL includes the following steps:

1. IVL catheter insertion: First, the catheter is inserted into the artery and navigated to the targeted calcified blockage.

2. Device inflation: Next, the angioplasty balloon is inflated within the diseased artery.

3. Sound wave emission: Once the IVL catheter is inflated, the generator powers the emitters to produce sound waves targeting the calcified plaque. The generator is designed to deliver consecutive pulses at a specified rate, which creates mechanical energy that fractures calcium deposits.

4. Device deflation: After targeting the plaque with a series of sound or shock waves, the balloon is deflated and the IVL catheter is removed.

5. Imaging evaluation: Post-treatment, the use of advanced intravascular imaging techniques help assess the effectiveness of the procedure. These techniques include both intravascular ultrasound (IVUS) and optical coherence tomography (OCT). These imaging techniques are used to detect calcium fractures in the plaque, helping the treating physician to determine what additional treatment is necessary. 

Improving IVL Treatment Outcomes with Intravascular Imaging

Medical professionals can use intravascular imaging techniques before and after the IVL procedure. These include intravascular ultrasound and optical coherence tomography, which help to assess and characterize severely calcified arteries. This imaging capability makes IVL a pivotal tool for doctors treating arterial diseases like CAD and PAD. The significance of imaging lies in these factors:

• Gauging calcium density: Precisely determining the calcium plaque’s density ensures that medical practitioners are well-informed about the plaque's composition.

• Selecting the right technique: By understanding the lesion's nature, clinicians can choose the most effective modification method, be it rotational atherectomy, orbital atherectomy, IVL, or other tools.

• Monitoring procedure progress: Real-time imaging offers a clear insight into the ongoing treatment, enabling adjustments when necessary.

• Confirming effective treatment: Post-procedure, intravascular imaging can help verify that the calcified plaque has been adequately addressed and broken down.

The Patient Experience During an IVL Procedure

IVL is typically a painless procedure for patients, aside from the discomfort of catheter insertion into the body. For a patient, going through an IVL procedure is similar to other catheter-based procedures like angioplasty or stent placement. IVL can be an outpatient or inpatient procedure and is usually performed in a room equipped with imaging machines.

1. Preparation: Before the procedure, the patient will undergo a thorough medical evaluation, which usually includes a physical exam, blood tests, and possibly imaging studies (like an angiogram). They will be informed about the procedure's details, potential risks, and benefits.

2. Mild sedation and local anesthesia: Some IVL patients are given mild sedation to help them relax. However, most patients remain awake during the procedure and can communicate with the medical team. Local anesthesia is applied at the site where the catheter will be inserted to numb the area and ensure the patient is comfortable.

3. Procedure: An IVL procedure is not expected to be painful or uncomfortable for the vast majority of patients. A nurse or physician will make a small puncture in the artery, typically in the groin (femoral artery). Through this entry point, a sheath is placed to allow catheters to be passed easily into the artery. Once the emitters begin to deliver sonic pressure waves, the patient may hear a faint clicking sound and feel a mild vibration. Additional treatments, like a stent placement, are typically used afterwards. The entire procedure may take anywhere from 30 minutes to several hours, depending on the complexity of the lesions and whether other interventions are also performed.

4. Post-procedure: Once an IVL procedure is complete, the catheter is removed, and the access site is closed, often with manual pressure or a vessel closure device. Patients are then monitored in a recovery area. They might need to lie flat for a period to ensure there's no bleeding from the access site. Depending on the procedure's specifics and the patient's overall health, they might be discharged the same day or might require a short hospital stay.

IVL Has an Excellent Safety Profile

IVL is mostly painless for patients. Peer-reviewed studies have also indicated that IVL has an excellent safety profile, with a low incidence of procedure-related complications. (1, 2) You can dive deeper into IVL safety and potential complications in this article.