Purpose:To assess the feasibility and safety of intravascular lithotripsy (IVL) for enabling transfemoral abdominal (EVAR), thoracic (TEVAR), and thoracoabdominal (BEVAR) endovascular aneurysm repair in patients with narrow and calcified iliac arteries.Materials and methods:Consecutive patients treated with IVL for severe calcified and narrowed iliac access before EVAR, TEVAR, or BEVAR between November 2020 and June 2022 were retrospectively evaluated. All anatomical iliac characteristics were acquired by multi-planar reconstruction of preoperative computed tomography angiography (CTA). The hostility of the vascular accesses was classified based on Peripheral Arterial Calcium Scoring System (PACSS) and calcified access severity score (CASS), a new score considering both anatomical (calcium grade and length, minimum lumen diameter [MLD], and tortuosity index) and aortic stent-graft (SG/MLD index) parameters. Primary endpoint was technical success defined as successful aortic endograft delivery and deployment without iliac rupture. Freedom from complications and primary patency were additionally analyzed.Results:Twenty-eight iliac axes were treated with IVL (8 bilateral) in 20 patients (mean age 74.5±6.7 years) with a mean follow-up of 26.5±6.2 (range 17–36) months. Ten patients underwent EVAR: 3 TEVAR, and 7 BEVAR procedures. In 14 patients (70%), aneurysm disease was associated with symptomatic aorto-iliac occlusive disease (AIOD), with Rutherford class III to IV. The PACSS was grade IV in 89% of the cases and the CASS (mean 14±2) was grade III to IV in all cases. The stent-graft (SG) outer diameter (5.60±1.65 mm) was significantly larger by 50% than MLD (3.96±1.20 mm), with an SG/MLD index of 1.50±0.51 (p<0.001). Technical success was 100%. No dissection, rupture, or distal embolization occurred. One (3.4%) bail-out stenting was necessary as endoconduit after IVL treatment. One month CTA showed that postoperative luminal gain increased by 93% (p<0.001). An improvement of 2 Rutherford classes occurred in all AIOD patients with a primary patency of 100% at last follow-up.Conclusions:This study shows the safety and feasibility of IVL as a valuable option to treat narrow and calcified iliac arteries to facilitate endograft delivery. Further studies will be useful to confirm these results.Clinical ImpactIn this article, the use of intravascular iliac artery lithotripsy to facilitate aortic endograft delivery is explored. The presence of iliac severe calcifications still represents a contraindication for aortic endovascular repair. Intravascular lithotripsy increases the feasibility and safety of endovascular aortic procedures, facilitating endograft delivery and reducing the risk of iliac rupture and/or dissections by improving vessel compliance and luminal gain. This novel vessel preparation could be an alternative to “paving and cracking” and/or iliac conduits. This study describes a new score to classify the severity of iliac calcifications, considering anatomical parameters and the profile of aortic endografts delivery system.

中文翻译：

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血管内髂动脉碎石术促进主动脉内移植物分娩：双中心经验的中期结果

目的：评估血管内碎石术 (IVL) 对狭窄和钙化髂动脉患者进行经股腹 (EVAR)、胸廓 (TEVAR) 和胸腹 (BEVAR) 血管内动脉瘤修复的可行性和安全性。材料和方法：连续患者回顾性评估 2020 年 11 月至 2022 年 6 月期间在 EVAR、TEVAR 或 BEVAR 之前接受 IVL 治疗的严重钙化和髂动脉狭窄的患者。所有髂骨解剖特征均通过术前计算机断层扫描血管造影（CTA）的多平面重建获得。血管通路的敌意根据外周动脉钙评分系统（PACSS）和钙化通路严重程度评分（CASS）进行分类，这是一种考虑解剖学（钙等级和长度、最小管腔直径 [MLD] 和迂曲指数）的新评分和主动脉覆膜支架（SG/MLD 指数）参数。主要终点是技术成功，定义为成功的主动脉内移植物输送和部署，且没有髂骨破裂。另外还分析了无并发症和主要通畅情况。 结果：20 名患者（平均年龄 74.5±6.7 岁）的 28 个髂轴接受了 IVL（8 个双侧）治疗，平均随访时间为 26.5±6.2（范围 17- 36）个月。 10 例患者接受了 EVAR：3 例 TEVAR 和 7 例 BEVAR 手术。在 14 名患者 (70%) 中，动脉瘤疾病与症状性主动脉髂闭塞性疾病 (AIOD) 相关，卢瑟福分级为 III 至 IV 级。 89% 的病例 PACSS 为 IV 级，所有病例 CASS（平均 14±2）为 III 至 IV 级。覆膜支架（SG）外径（5.60±1.65 mm）比MLD（3.96±1.20 mm）显着大50%，SG/MLD指数为1.50±0.51（p<0.001）。技术成功率为 100%。未发生夹层、破裂或远端栓塞。 IVL 治疗后需要置入 1 例 (3.4%) 应急支架作为导管内支架。 1个月CTA显示术后管腔增益增加93%（p<0.001）。所有 AIOD 患者的卢瑟福等级均获得 2 级改善，末次随访时初次通畅率为 100%。结论：本研究表明 IVL 作为治疗狭窄和钙化髂动脉以促进内移植物输送的有价值的选择的安全性和可行性。进一步的研究将有助于证实这些结果。临床影响在本文中，探讨了使用血管内髂动脉碎石术来促进主动脉内移植物的输送。髂骨严重钙化的存在仍然是主动脉血管内修复的禁忌症。血管内碎石术增加了血管内主动脉手术的可行性和安全性，通过改善血管顺应性和管腔增益，促进内移植物的输送并降低髂骨破裂和/或夹层的风险。这种新颖的血管制备可以作为“铺路和破裂”和/或髂导管的替代方案。这项研究描述了一种新的评分来对髂骨钙化的严重程度进行分类，考虑解剖参数和主动脉内移植物输送系统的轮廓。