Intravascular lithotripsy (IVL) is a groundbreaking technology in percutaneous coronary intervention (PCI) for treating calcified coronary artery disease (CAD). IVL is like extracorporeal lithotripsy, which uses shock waves to break up kidney stones. IVL fractures calcified plaques within the coronary artery using sonic pressure waves. The device is a specialized balloon catheter with emitters that produce pulsatile acoustic waves. These waves propagate through the vessel wall during balloon inflation at low pressures (4-6 atm), causing microfractures in both superficial and deep calcium deposits. This process enhances vessel compliance, facilitating subsequent low-pressure balloon dilation and optimal stent expansion.¹ IVL uses a familiar balloon-based platform and conventional guidewire, leading to a much shorter learning curve of device use for interventional cardiologists.

The ideal candidates for coronary IVL are patients with moderately to severely calcified coronary lesions. IVL is considered in highly calcified lesions defined as having a severe calcium arc (>270 degrees) or calcium thickness >0.5 mm.¹ The most suitable target for IVL is arterial circumferential calcification. IVL might be suitable for eccentric lesions, as well.¹ It is a feasible and effective lesion preparation strategy for calcified nodules. The safety and efficacy of IVL in calcified nodules was evaluated in the DISRUPT CAD (Shockwave Coronary Lithoplasty Study) I-IV pivotal trials, whose results showed that it was a highly effective modality with similar procedural outcomes to those of plate-like lesions in terms of residual area stenosis, stent expansion, and acute luminal gain.² In nodular lesions, more pulses may be required to modify eccentric calcium because the emitter is farther away. If all IVL pulses have been applied to the nodule and a noncompliant balloon inflation is not effective, an additional round of IVL with a new catheter may be needed to achieve full expansion.¹ If the IVL balloon fully expands in the lesion, then fracture has been achieved. This achievement is in contrast to atherectomy, in which it is less clear whether full treatment of calcification has been achieved until a balloon is expanded in the lesion.

IVL in Left Main Coronary Artery Bifurcation Lesions

High technical success is observed with IVL-assisted PCI in calcified left main coronary artery lesions.³ One advantage of IVL in a calcified bifurcation is that the side-branch wire does not need to be removed to modify plaque in the main branch. IVL can be advanced over a workhorse guidewire in the main branch in the presence of another guidewire in the side branch. This approach is in contrast to rotational or orbital atherectomy, both of which necessitate specialized guidewires and removal of the side-branch wire. A wire cannot be kept in the side branch during rotational or orbital atherectomy due to the possibility of wire fracture and embolization, although a wire can be kept in the side branch for laser atherectomy. By using sonic waves, it also circumvents the risks of distal embolization associated with atherectomy's mechanical debulking. The device applies unfocused acoustic energy circumferentially, modifying the entire calcified plaque regardless of wire bias, a limitation of some atherectomy devices. IVL penetrates deeply to fracture both intimal and medial calcifications, ensuring improved vessel compliance, in contrast to atherectomy, which primarily targets superficial calcium.⁴

An additional advantage of IVL is the possible beneficial effect of shockwaves on adjacent calcifications at the side-branch ostium, which may enhance ostial compliance and facilitate greater stent expansion in this region.⁵ The need for prolonged vessel occlusion to deliver the required energy in the left main coronary artery, which can cause severe ischemia, might be mitigated by distributing the energy by providing pulses individually or in small groups with shorter balloon inflations to minimize this risk.¹

IVL has several disadvantages, however. The IVL catheter may still have difficulty with crossing in extremely tight or severely tortuous lesions, occasionally requiring preliminary use of a smaller balloon or hybrid atherectomy approach. The limited balloon length (12 mm) of IVL catheters may be a disadvantage for treating long, diffuse calcified segments. This limitation is addressed by the more recent Shockwave C2+ platform (Shockwave Medical), which delivers more pulses per catheter. The shockwaves can cause temporary and self-limiting arrhythmias, especially in patients with pre-existing bradycardia or during treatment of the right coronary artery.¹

IVL in Challenging Lesion Subsets

IVL can be used as an adjunctive therapy in chronic total occlusions (CTO), in which heavily calcified lesions present a significant challenge for other crossing or revascularization devices.⁶ IVL of the side branch may also modify the proximal cap of a CTO to facilitate anterograde wiring.⁷ IVL has also been successfully employed to treat underexpanded stents caused by resistant calcium, an off-label use.⁸ It is unclear whether an antiproliferative drug is required following IVL or whether the acoustic burst on metallic scaffolding could alter the stent or polymer coating, but leaving an underexpanded stent untreated is considered more risky in the short term for stent thrombosis or in-stent restenosis. Additional data are needed for the challenging lesion subsets of CTO and underexpanded stents. Potential future directions include non–balloon-based systems and improving the user interface and pulse delivery. Longer, low-profile catheters and larger diameters could further broaden its utility. Ongoing research will further explore IVL's position in the algorithm for calcified lesion treatment relative to noncompliant and cutting balloons and its combination with atherectomy.

More data are needed on its long-term safety and efficacy in a broader range of lesion subsets. In the recent Short-CUT (Shockwave Lithoplasty Compared to Cutting Balloon Treatment in Calcified Coronary Disease) trial, cutting balloon angioplasty performed as well as IVL for minimal stent area on imaging at 30 days with similar safety.⁹ In the subset with atherectomy, cutting balloon angioplasty had similar calcium fractionation and stent expansion but did not meet noninferiority for minimal stent area, which may be related to vessel size. In the VICTORY (Randomized Trial of Intravascular Lithotripsy and Super-High-Pressure Non-Compliant Balloons for Treatment of Calcified and Refractory Coronary Lesions), super-high-pressure balloon inflation gave similar stent expansion as IVL.¹⁰ In light of these findings, IVL may be positioned as the tool saved for recalcitrant calcification for which other tools have not adequately modified plaque with or without atherectomy. As technology evolves and more data become available, clinicians will better understand the position of IVL in the armamentarium for calcified CAD.

References

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8. Leick J, Rheude T, Denne M, et al. Comparison of long-term outcome in patients with in-stent restenosis treated with intravascular lithotripsy or with modified balloon angioplasty. Clin Res Cardiol. 2024;113(7):1030-1040. doi:10.1007/s00392-023-02357-3
9. Baron SJ. The Short-CUT Trial: Shockwave lithotripsy compared to cutting balloon treatment in calcified coronary artery disease. Presented at Transcatheter Cardiovascular Therapeutics (TCT) 2025, San Francisco, CA. October 26, 2025.
10. Alasnag M. A randomised, multicenter, non-inferiority comparison of intravascular lithotripsy and super-high-pressure non-compliant balloons for treatment of calcified and refractory coronary lesions – The VICTORY trial (PCR online website). 2025. Available at: https://www.pcronline.com/News/Whats-new-on-PCRonline/2025/TCT/VICTORY-Intravascular-lithotripsy-vs.-super-high-pressure-PTCA-in-calcified-and-refractory-coronary-lesions. Accessed 01/13/2026.