Cracking the Calcium Barrier: Intravascular Lithotripsy for Peripheral Arterial Disease—1-year Outcomes From 50 Procedures in a Singapore Tertiary Hospital

This study reports our experience with intravascular lithotripsy (IVL) in managing heavily calcified peripheral arterial disease (PAD) at a tertiary center in Southeast Asia. A total of 50 procedures were performed in 49 patients between October 2022 and April 2024. The cohort had a high burden of comorbidities, with 94% presenting with chronic limb-threatening ischemia, 62% classified as wound, ischemia, and foot infection (WIfI) stage 4, and 31% having end-stage renal failure. Severe vascular calcification (Peripheral Artery Calcification Scoring System [PACSS] grade 4) was present in 84% of lesions. IVL was employed as a vessel preparation strategy prior to definitive treatment, with adjunctive therapies used in all cases. Technical success was achieved in 100% of procedures, with a mean luminal gain of 71.4%±21.8%. Bailout stenting was required in 16% of cases, and there were no incidents of distal embolization. At 1-year follow-up, the target lesion revascularization rate was 6.1%, the overall reintervention rate was 14%, limb salvage was 84%, and mortality was 31%. Our findings suggest that IVL is a safe and effective option for vessel preparation in patients with severely calcified PAD, achieving high technical success and favorable mid-term outcomes in a complex, high-risk population.Clinical ImpactCalcified peripheral arterial disease remains a challenging subset in endovascular therapy, often limiting luminal gain, increasing dissection risk, and impairing drug delivery. This single-center experience demonstrates that IVL is a safe and effective vessel-preparation strategy in a real-world population with high comorbidity burden and predominantly PACSS grade 4 disease. IVL achieved 100% technical success, substantial luminal gain, low complication rates; and favorable 1-year limb salvage and reintervention outcomes. These findings support IVL as a practical method for modifying severe calcification and improving procedural reliability in high-risk patients undergoing endovascular treatment.