Case Report: Intravascular lithotripsy combined with a new-generation 3-in-1 carotid stent for calcified carotid artery stenosis.

BACKGROUND

Symptomatic carotid atherosclerotic stenosis is a major cause of ischemic stroke. In patients with heavily calcified plaque and limited physiologic reserve for open revascularization, conventional carotid artery stenting may fail because rigid calcium prevents adequate luminal expansion. Intravascular lithotripsy (IVL) is an adjunctive plaque-modification strategy for selected calcified carotid lesions, although evidence remains limited and carotid IVL is investigational.

CASE PRESENTATION: An 83-year-old man with hyperlipidemia, hypertension, hypothyroidism, protein S deficiency, prior myocardial infarction, and lower-extremity deep vein thrombosis on apixaban presented with acute ischemic stroke manifested by dysarthria, global aphasia, and right hemiparesis. Brain MRI showed acute left-hemisphere borderzone infarcts involving deep white matter and basal ganglia, consistent with ipsilateral carotid atheroembolism and/or relative hypoperfusion. CTA and cerebral angiography demonstrated approximately 60% left internal carotid artery stenosis, with heavy concentric calcification spanning a lesion length greater than 10 mm at the carotid bifurcation.

MANAGEMENT AND OUTCOME: After multidisciplinary review of carotid endarterectomy, TCAR, and transfemoral options, IVL-assisted carotid angioplasty and stenting under continuous embolic protection was selected given advanced age, prior myocardial infarction, acute neurologic impairment, and limited functional reserve. Using distal embolic protection and proximal balloon-guide flow arrest, IVL was performed across the calcified plaque, followed by deployment of a new-generation integrated 3-in-1 carotid stent. Angiographic stenosis improved from approximately 60% to approximately 20% by NASCET methodology without periprocedural stroke, vasospasm, dissection, hemodynamic instability, or access-site complication. Admission NIHSS was 29; discharge NIHSS and mRS were 6 and 3, respectively. At approximately 1-month follow-up he was alert and oriented ×3 with fluent language and good comprehension. No further antithrombotic regimen switch occurred during outpatient follow-up, and no perioperative complications were reported.

CONCLUSION

In this elderly patient with acute ischemic stroke and heavily calcified symptomatic carotid stenosis, IVL with angioplasty and a 3-in-1 carotid stent achieved early technical success without periprocedural complication and with short-term clinical stability. This case supports further investigation of IVL-based carotid revascularization in carefully selected patients who are poor candidates for open surgery and highlights the need for standardized follow-up, neurologic outcome reporting, and prospective evaluation of long-term patency and stroke prevention.