Outcomes of intravascular lithotripsy for calcified femoropopliteal and infrapopliteal artery disease: A systematic review with qualitative synthesis.

BACKGROUND

Heavily calcified peripheral artery disease (PAD) lesions limit the effectiveness of standard endovascular techniques and increase complication risk. This study systematically evaluates the safety and efficacy of intravascular lithotripsy (IVL) as a calcium-modifying therapy.

METHODS

A systematic literature search was performed using PubMed, Scopus, and Web of Science for studies published between 2020 and July 2025. Studies investigating the use of IVL in calcified femoropopliteal and infrapopliteal arteries were included. Inclusion criteria encompassed observational and interventional designs reporting procedural, safety, or efficacy outcomes. Studies not utilizing IVL as a primary therapy or lacking calcified lesions were excluded.

RESULTS

14 studies met the inclusion criteria, comprising single-arm cohorts, registries, and randomized controlled trials. IVL consistently demonstrated high procedural success (>95%), low rates of major dissection (≤5.5%), minimal perforation (≤1.1%), and a reduced need for bailout stenting compared to conventional angioplasty. Compared to atherectomy, IVL showed a superior safety profile with lower rates of perforation and distal embolization. Relative to high-pressure balloons, IVL achieved similar luminal gain with significantly fewer flow-limiting dissections.

CONCLUSION

IVL is a safe and effective technique for modifying calcified plaques in peripheral arteries, addressing key limitations of conventional endovascular approaches. By providing a controlled and predictable mechanism for vessel preparation, IVL represents a valuable treatment option in selected patients with heavily calcified peripheral artery disease and may facilitate durable revascularization with a favorable safety profile.