Has IVL replaced atherectomy?

Below-the-knee (BTK) arterial disease remains one of the more challenging areas in vascular care, particularly in patients with chronic limb-threatening ischemia (CLTI), where heavy calcification complicates endovascular treatment. As new calcium-modifying technologies emerge, an important question remains: what evidence supports their use in BTK interventions? In this episode of BackTable Vascular & Interventional, host Dr. Sabeen Dhand speaks with vascular surgeon Dr. Paul Foley of Doylestown Health about the Disrupt BTK II clinical trial from Shockwave Medical, which evaluates the performance of peripheral intravascular lithotripsy (IVL) in heavily calcified BTK disease.

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This podcast is supported by:

Shockwave Medical
https://shockwavemedical.com/

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SYNPOSIS

Dr. Foley begins by outlining his training and the evolution of his vascular surgery practice, setting the stage for a broader discussion on how BTK interventions have changed over the past decade. The conversation explores shifts in access strategies, procedural approaches, and the unique characteristics of calcification encountered in CLTI. Because BTK calcium differs from calcification seen elsewhere in the peripheral vasculature, imaging and device selection play a particularly important role when planning IVL-based therapies. Dr. Foley reviews the design and outcomes of the Disrupt BTK II trial, where devices such as the Shockwave M5+ and S4 catheters were used to modify calcified plaque, demonstrating encouraging safety and performance signals.

The discussion then turns to emerging technologies, including Shockwave’s Javelin catheter, designed to deliver focused pressure waves to fracture dense calcium within peripheral arteries. Dr. Foley describes how the device fits into BTK workflows, including technique considerations and its use alongside adjunctive therapies such as balloon angioplasty. The episode also addresses the ongoing skepticism surrounding IVL in BTK disease, emphasizing the need for careful patient selection, procedural precision, and continued multidisciplinary collaboration as the field works to refine treatment strategies and improve outcomes for patients with peripheral artery disease (PAD).

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TIMESTAMPS

00:00 - Introduction
08:20 - Evolution of Below-the-Knee Treatments
11:10 - Differences in BTK Calcification
13:13 - Imaging and Technology in BTK Interventions
15:18 - Disrupt BTK II Trial Data and Results
23:17 - Introduction to the Javelin Device
26:39 - Technique Considerations with Javelin
28:36 - Comparing Javelin and E8
31:17 - Future Directions for Lithotripsy Technology
35:30 - Skepticism Around IVL in BTK Disease
38:47 - Final Thoughts

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RESOURCES

Disrupt BTK II Trial
https://www.jvascsurg.org/article/S0741-5214(24)02063-9/fulltext