Pre-Stenting Lesion Preparation Using Shockwave Intravascular Lithotripsy in Severely Calcified Superior Mesenteric Artery Stenosis

Pre-Stenting Lesion Preparation Using Shockwave Intravascular Lithotripsy in Severely Calcified Superior Mesenteric Artery Stenosis | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Pre-Stenting Lesion Preparation Using Shockwave Intravascular Lithotripsy in Severely Calcified Superior Mesenteric Artery Stenosis Robert Terzis, Robert Wawer Matos Reimer, David Maintz, Erkan Celik This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7515486/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 07 Jan, 2026 Read the published version in CVIR Endovascular → Version 1 posted 4 You are reading this latest preprint version Abstract Background Intravascular lithotripsy (IVL) is an emerging technique for modifying heavily calcified arterial lesions, with primary application in peripheral arteries. We report the use of IVL for lesion preparation prior to stenting in a patient with severely calcified superior mesenteric artery (SMA) stenosis. Case Presentation: A 66-year-old man with type I adenocarcinoma of the esophagogastric junction (AEG Type I) and neoadjuvant FLOT chemotherapy was scheduled for Ivor Lewis esophagectomy. Preoperative CT angiography revealed a high-grade ostial SMA stenosis due to extensive atherosclerotic calcification. To mitigate the risk of postoperative mesenteric hypoperfusion, percutaneous endovascular revascularization was performed. Following initial predilation, IVL using a Shockwave 5.5 × 60 mm balloon catheter was employed for lesion preparation. Subsequently, an 8.0 x 24 mm balloon-expandable stent was successfully deployed with minimal residual stenosis and no complications. Conclusion This case demonstrates that IVL represents a feasible and effective adjunct in the management of severely calcified visceral arterial lesions, facilitating adequate lesion preparation and improved stent expansion. IVL may therefore be considered as a therapeutic option in selected patients. Intravascular lithotripsy Superior mesenteric artery stenosis Mesenteric ischemia Shockwave Visceral intervention Figures Figure 1 Figure 2 Figure 3 Background Chronic mesenteric ischemia (CMI) commonly results from atherosclerotic narrowing of the mesenteric arteries and typically presents with postprandial pain and weight loss [ 1 ]. However, incidental SMA stenosis may also be detected during cancer staging or preoperative imaging. The SMA is the primary vessel supplying the small intestine. Its obstruction, especially in the context of limited collateral flow, can lead to clinically significant ischemia during physiologic stress, such as major abdominal surgery [ 2 , 3 ]. Endovascular treatment options include percutaneous transluminal angioplasty (PTA) with stent placement [ 4 ]. However, dense calcification poses technical challenges and increases the risk of perforation, suboptimal expansion, recoil, or dissection [ 4 ]. Intravascular lithotripsy (IVL) has recently emerged as an innovative approach that facilitates calcium modification using sonic pressure waves to fracture intimal and medial calcifications, thus enhancing vessel compliance prior to stenting [ 5 , 6 ]. Case Presentation A 66-year-old male patient was diagnosed with adenocarcinoma of the esophagogastric junction type I (AEG Type I), with tumor extension from 40 to 44 cm from the alveolar ridge. He completed neoadjuvant chemotherapy per FLOT protocol. Follow-up CT staging revealed a regressive tumor with no distant metastases (cT2N0M0) but incidentally showed a high-grade ostial SMA stenosis due to heavily calcified atherosclerotic plaque, with an adjacent exophytic component extending into the aortic lumen. Given the impending Ivor Lewis esophagectomy and known hemodynamic dependence on SMA perfusion, interdisciplinary consensus recommended preoperative endovascular revascularization. Under local anesthesia and continuous monitoring, percutaneous access was obtained via the right common femoral artery. A short 5 Fr sheath was introduced and exchanged for a 7 Fr steerable long sheath (Lamed GmbH, Oberhaching, Germany). A diagnostic angiogram confirmed a subtotal ostial SMA stenosis (Fig. 1 ). After intraluminal recanalization, a 3.0 × 40 mm conventional balloon catheter (Sterling, Boston Scientific, Marlborough, MA, USA) was used for predilatation. Subsequently, a 5.5 × 60 mm Shockwave™ IVL balloon catheter (Shockwave Medical Inc., Santa Clara, CA, USA) was advanced into the SMA and four full cycles of 30 electric pulses of lithotripsy were performed to treat the lesion (Fig. 2 ). An 8.0 × 24 mm Formula™ balloon-expandable stent (Cook Medical, Bloomington, IN, USA) was then implanted from the SMA ostium into the proximal main stem. Post-stenting angiography revealed a good angiographic result with a widely patent vessel and only minimal residual stenosis (Fig. 3 ). The arterial puncture site was closed by manual compression, followed by application of a compression bandage. There were no peri- or postprocedural complications. The Ivor Lewis esophagectomy was successfully carried out as scheduled, without perioperative complications related to intestinal perfusion. Discussion Endovascular revascularization has become the preferred treatment modality for chronic mesenteric ischemia due to its lower morbidity and mortality compared to open surgery, especially in high-risk surgical candidates or in the preoperative setting of major abdominal surgery [ 2 – 4 ]. However, severe ostial calcifications remain a major technical challenge, often impairing optimal stent deployment and increasing the risk of vessel perforation, elastic recoil, dissection, or restenosis [ 7 ]. IVL has recently emerged as a promising adjunctive technology to address these limitations. IVL uses pulsatile sonic pressure waves to fracture both intimal and medial calcium, thereby enhancing vessel compliance while minimizing trauma to the surrounding tissue [ 8 ]. Unlike atherectomy or high-pressure ballooning, IVL preserves the structural integrity of the vessel and does not generate particulate debris, reducing the risk of distal embolization [ 9 , 10 ]. To date, most of the available data are derived from peripheral and coronary interventions, with large multicenter trials such as the DISRUPT PAD III and CAD III trials demonstrating the safety and efficacy of IVL in treating heavily calcified femoropopliteal and coronary lesions [ 10 , 11 ]. In the latest report from the DISRUPT PAD III trial, IVL treatment of 164 common femoral artery lesions, 95.1% of which had moderate to severe calcification, resulted in a final residual stenosis of 23.6 ± 11.5% with no major vascular complications observed by core-laboratory assessment, underscoring its favorable safety profile even in anatomically complex and calcified vascular beds [ 5 ]. Specific evidence for IVL in the SMA is currently restricted to isolated case reports. Our findings are consistent with previous reports summarized in the most comprehensive review to date by Spath et al. [ 6 ], who compiled 11 cases involving IVL treatment of severely calcified visceral and renal arteries. The majority of cases (67%) addressed chronic mesenteric ischemia, with the SMA being the most frequently treated vessel [ 6 ]. Across all cases, IVL demonstrated high technical success, with no reported complications such as vessel perforation, distal embolization, or thrombosis. Most procedures involved predilatation followed by IVL and stent implantation, approaches that mirror the technique applied in our case. The number of lithotripsy pulses varied widely (150–300), and both covered and uncovered stents were used, depending on vessel anatomy and operator preference [ 6 , 12 ]. Our case adds to this evolving body of evidence by demonstrating the successful use of IVL as a preparatory step for stenting in the SMA. Importantly, revascularization with restoration of adequate luminal patency was imperative due to the patient’s oncologic status and the anticipated risk of mesenteric hypoperfusion after the planned surgical procedure. IVL facilitated successful low-pressure stent deployment. The use of a 5.5 × 60 mm Shockwave™ balloon and four cycles of intravascular lithotripsy in our case aligns with the range reported in previously published cases. Notably, this approach enabled the successful deployment of an 8 mm balloon-expandable stent, a diameter rarely achieved in the SMA due to its typically narrow caliber. Spath et al. reported stent implantation with a 7 mm diameter following lesion preparation using an 8 × 60 mm IVL balloon. Remarkably, in our case, the deployment of an 8 mm diameter stent was achieved after preparation with a smaller 5.5 × 60 mm balloon, representing the largest reported discrepancy between IVL balloon and stent diameter in the current literature. This observation suggests that effective lesion preparation may be achievable even with smaller balloon diameters, underscoring the safety and efficacy of intravascular lithotripsy in addressing the biomechanical challenges posed by dense vascular calcification. By facilitating controlled plaque modification, it enabled the deployment of a larger-diameter stent than it might have been achievable with conventional balloon angioplasty alone. This case supports the expanding utility of IVL beyond peripheral and coronary interventions, particularly in anatomically complex vascular territories such as the mesenteric circulation. Despite the encouraging results, the collective experience remains limited to a small number of patients. Future prospective studies are warranted to assess long-term outcomes and better define selection criteria, especially in preoperative settings like ours. Conclusion In conclusion, IVL represents a valuable adjunct for lesion preparation in the treatment of heavily calcified SMA stenoses, particularly when optimal stent expansion is required. This technique may be especially beneficial in the preoperative management of oncologic patients undergoing major abdominal surgery, where mesenteric perfusion must be safeguarded. Further prospective studies are necessary to validate long-term outcomes. Abbreviations SMA – Superior mesenteric artery IVL – Intravascular lithotripsy PTA – Percutaneous transluminal angioplasty CTA – Computed tomography angiography CMI – Chronic mesenteric ischemia Declarations Ethics approval and consent to participate All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 declaration of Helsinki. Consent for publication Written informed consent was obtained from the patient for publication of this case report and any accompanying images. Availability of data and materials Not applicable. Competing interests The authors declare that they have no competing interests. Funding The authors state that this work has not received any funding. Authors’ contributions Robert Terzis : Conceptualization, Investigation, Visualization, Writing - Original Draft, Writing - Review & Editing; Robert Wawer Matos Reimer : Conceptualization, Validation, Writing - Review & Editing; David Maintz : Validation, Writing - Review & Editing, Supervision, Project Administration; Erkan Celik : Conceptualization, Validation, Investigation, Visualization, Writing - Original Draft, Writing - Review & Editing. Acknowledgements Not applicable. References Hansen, K.J., et al., Mesenteric artery disease in the elderly. J Vasc Surg, 2004. 40 (1): p. 45-52. Huber, T.S., et al., Chronic mesenteric ischemia: Clinical practice guidelines from the Society for Vascular Surgery. J Vasc Surg, 2021. 73 (1s): p. 87s-115s. Lejay, A., et al., Chronic mesenteric ischemia: 20 year experience of open surgical treatment. Eur J Vasc Endovasc Surg, 2015. 49 (5): p. 587-92. Terlouw, L.G., et al., European guidelines on chronic mesenteric ischaemia - joint United European Gastroenterology, European Association for Gastroenterology, Endoscopy and Nutrition, European Society of Gastrointestinal and Abdominal Radiology, Netherlands Association of Hepatogastroenterologists, Hellenic Society of Gastroenterology, Cardiovascular and Interventional Radiological Society of Europe, and Dutch Mesenteric Ischemia Study group clinical guidelines on the diagnosis and treatment of patients with chronic mesenteric ischaemia. United European Gastroenterol J, 2020. 8 (4): p. 371-395. Shammas, N.W., et al., Intravascular Lithotripsy for Treatment of Severely Calcified Common Femoral Artery Disease: Results From the Disrupt PAD III Observational Study. J Endovasc Ther, 2024: p. 15266028241255622. Spath, P., et al., Use of Shockwave Intravascular Lithotripsy in Recanalization of Calcified Visceral and Renal Arteries: A Case Report and Update of the Literature. J Endovasc Ther, 2024. 31 (3): p. 485-490. van Petersen, A.S., et al., Open or percutaneous revascularization for chronic splanchnic syndrome. J Vasc Surg, 2010. 51 (5): p. 1309-16. Brodmann, M., et al., Safety and Performance of Lithoplasty for Treatment of Calcified Peripheral Artery Lesions. J Am Coll Cardiol, 2017. 70 (7): p. 908-910. Beattie, W.S., et al., Survival After Isolated Post-Operative Troponin Elevation. J Am Coll Cardiol, 2017. 70 (7): p. 907-908. Brinton, T.J., et al., Feasibility of Shockwave Coronary Intravascular Lithotripsy for the Treatment of Calcified Coronary Stenoses. Circulation, 2019. 139 (6): p. 834-836. Adams, G., et al., Intravascular Lithotripsy for Treatment of Calcified Lower Extremity Arterial Stenosis: Initial Analysis of the Disrupt PAD III Study. J Endovasc Ther, 2020. 27 (3): p. 473-480. Balboa Arregui, O., et al., Use of Shockwave intravascular lithotripsy for the treatment of symptomatic and severely calcified superior mesenteric artery stenosis. CVIR Endovasc, 2021. 4 (1): p. 53. Cite Share Download PDF Status: Published Journal Publication published 07 Jan, 2026 Read the published version in CVIR Endovascular → Version 1 posted Reviewers agreed at journal 08 Sep, 2025 Reviewers invited by journal 08 Sep, 2025 Editor assigned by journal 05 Sep, 2025 First submitted to journal 03 Sep, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7515486","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":511629631,"identity":"e63aa07c-1715-4975-8916-4f3053310bab","order_by":0,"name":"Robert Terzis","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABAUlEQVRIie2PP0rEQBjF3yC4zYS0E3TvkCUwKRzYqyQMaOMBFESmis3+aVcQz2C12JlhYG2G9QorewHTJZ1JVrEaSbnF/KqPD3689wCP5yihf2eJG8T9YwcQ9a+SgR0U+6NkQxWQYoCSPsz1/rbGfXj2/qmbZ5OAGr3LXzFeOpRzu5UT26ZEiywzwdpwBIWMc4vk0RHD2DWPVKvEFqUhayOmH5SzvED+UjqVtOmUqSVKN09GIKRp3SlvboWTPoWeoAxUV2zG0ac4tjC6lZG6ZNHKnsLQzVU7fyPbYixZuVJGc10pIcJwNtpX9d3FRFGpv6pCjJeO+b/mgI/H4/F4hvMNssxV4dK5RVgAAAAASUVORK5CYII=","orcid":"https://orcid.org/0009-0007-1068-8477","institution":"University Hospital Cologne: Universitatsklinikum Koln","correspondingAuthor":true,"prefix":"","firstName":"Robert","middleName":"","lastName":"Terzis","suffix":""},{"id":511629632,"identity":"8a824726-d308-4760-870c-47562c4e8f6b","order_by":1,"name":"Robert Wawer Matos Reimer","email":"","orcid":"","institution":"University Hospital Cologne: Universitatsklinikum Koln","correspondingAuthor":false,"prefix":"","firstName":"Robert","middleName":"Wawer Matos","lastName":"Reimer","suffix":""},{"id":511629633,"identity":"671b5d11-cde4-4be7-bce0-0fddc18ac24a","order_by":2,"name":"David Maintz","email":"","orcid":"","institution":"University Hospital Cologne: Universitatsklinikum Koln","correspondingAuthor":false,"prefix":"","firstName":"David","middleName":"","lastName":"Maintz","suffix":""},{"id":511629634,"identity":"03da5413-7dc0-46a0-b998-70df7b9afeee","order_by":3,"name":"Erkan Celik","email":"","orcid":"","institution":"University Hospital Cologne: Universitatsklinikum Koln","correspondingAuthor":false,"prefix":"","firstName":"Erkan","middleName":"","lastName":"Celik","suffix":""}],"badges":[],"createdAt":"2025-09-02 08:51:31","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7515486/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7515486/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s42155-025-00622-2","type":"published","date":"2026-01-07T15:57:28+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":91370826,"identity":"2d1dfff2-3b5b-4db0-a448-181bca10ae4b","added_by":"auto","created_at":"2025-09-15 18:47:10","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":349609,"visible":true,"origin":"","legend":"\u003cp\u003eSelective angiography via femoral access confirmed a severe stenosis of the superior mesenteric artery. Pre-interventional CTA demonstrated a heavily calcified atherosclerotic plaque at the SMA origin, with an adjacent exophytic component extending into the abdominal aortic lumen.\u003c/p\u003e","description":"","filename":"Figure1final.png","url":"https://assets-eu.researchsquare.com/files/rs-7515486/v1/c42e14977eba47dd5a591fb3.png"},{"id":91372596,"identity":"94c5203c-7693-4fbf-8c9e-742d98d68fa9","added_by":"auto","created_at":"2025-09-15 19:03:10","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":454027,"visible":true,"origin":"","legend":"\u003cp\u003eInitial (left) and final (right) cycles of intravascular lithotripsy using a 5.5 x 60 mm Shockwave balloon catheter, demonstrating complete coverage of the stenotic segment. Note how the application of sonic pressure waves progressively modifies the calcified plaque, facilitating gradual balloon expansion and improved vessel compliance over the course of treatment.\u003c/p\u003e","description":"","filename":"Figure2final.png","url":"https://assets-eu.researchsquare.com/files/rs-7515486/v1/9c62cabc689c3ae9984eb287.png"},{"id":91370808,"identity":"ef76e45f-9b21-4fc2-94ac-c1a62d3acb44","added_by":"auto","created_at":"2025-09-15 18:47:10","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":395850,"visible":true,"origin":"","legend":"\u003cp\u003ePost-treatment angiography following IVL and implantation of an 8.0 × 24 mm Formula balloon-expandable stent demonstrates successful revascularization of the SMA. Multiplanar reconstruction of the follow-up CTA after Ivor Lewis esophagectomy confirms sustained vessel patency without evidence of restenosis or perioperative vascular compromise.\u003c/p\u003e","description":"","filename":"Figure3final.png","url":"https://assets-eu.researchsquare.com/files/rs-7515486/v1/dc0a657de050bbf281c69d1c.png"},{"id":100069386,"identity":"e4c21944-67a7-4306-aeaa-ddacfe90e354","added_by":"auto","created_at":"2026-01-12 16:13:45","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1565101,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7515486/v1/cd9542dd-ef5f-4977-a8e6-48c97252011c.pdf"}],"financialInterests":"","formattedTitle":"Pre-Stenting Lesion Preparation Using Shockwave Intravascular Lithotripsy in Severely Calcified Superior Mesenteric Artery Stenosis","fulltext":[{"header":"Background","content":"\u003cp\u003eChronic mesenteric ischemia (CMI) commonly results from atherosclerotic narrowing of the mesenteric arteries and typically presents with postprandial pain and weight loss [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. However, incidental SMA stenosis may also be detected during cancer staging or preoperative imaging. The SMA is the primary vessel supplying the small intestine. Its obstruction, especially in the context of limited collateral flow, can lead to clinically significant ischemia during physiologic stress, such as major abdominal surgery [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eEndovascular treatment options include percutaneous transluminal angioplasty (PTA) with stent placement [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. However, dense calcification poses technical challenges and increases the risk of perforation, suboptimal expansion, recoil, or dissection [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Intravascular lithotripsy (IVL) has recently emerged as an innovative approach that facilitates calcium modification using sonic pressure waves to fracture intimal and medial calcifications, thus enhancing vessel compliance prior to stenting [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e"},{"header":"Case Presentation","content":"\u003cp\u003eA 66-year-old male patient was diagnosed with adenocarcinoma of the esophagogastric junction type I (AEG Type I), with tumor extension from 40 to 44 cm from the alveolar ridge. He completed neoadjuvant chemotherapy per FLOT protocol. Follow-up CT staging revealed a regressive tumor with no distant metastases (cT2N0M0) but incidentally showed a high-grade ostial SMA stenosis due to heavily calcified atherosclerotic plaque, with an adjacent exophytic component extending into the aortic lumen. Given the impending Ivor Lewis esophagectomy and known hemodynamic dependence on SMA perfusion, interdisciplinary consensus recommended preoperative endovascular revascularization.\u003c/p\u003e\u003cp\u003eUnder local anesthesia and continuous monitoring, percutaneous access was obtained via the right common femoral artery. A short 5 Fr sheath was introduced and exchanged for a 7 Fr steerable long sheath (Lamed GmbH, Oberhaching, Germany). A diagnostic angiogram confirmed a subtotal ostial SMA stenosis (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eAfter intraluminal recanalization, a 3.0 \u0026times; 40 mm conventional balloon catheter (Sterling, Boston Scientific, Marlborough, MA, USA) was used for predilatation. Subsequently, a 5.5 \u0026times; 60 mm Shockwave\u0026trade; IVL balloon catheter (Shockwave Medical Inc., Santa Clara, CA, USA) was advanced into the SMA and four full cycles of 30 electric pulses of lithotripsy were performed to treat the lesion (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eAn 8.0 \u0026times; 24 mm Formula\u0026trade; balloon-expandable stent (Cook Medical, Bloomington, IN, USA) was then implanted from the SMA ostium into the proximal main stem. Post-stenting angiography revealed a good angiographic result with a widely patent vessel and only minimal residual stenosis (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eThe arterial puncture site was closed by manual compression, followed by application of a compression bandage. There were no peri- or postprocedural complications. The Ivor Lewis esophagectomy was successfully carried out as scheduled, without perioperative complications related to intestinal perfusion.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eEndovascular revascularization has become the preferred treatment modality for chronic mesenteric ischemia due to its lower morbidity and mortality compared to open surgery, especially in high-risk surgical candidates or in the preoperative setting of major abdominal surgery [\u003cspan additionalcitationids=\"CR3\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. However, severe ostial calcifications remain a major technical challenge, often impairing optimal stent deployment and increasing the risk of vessel perforation, elastic recoil, dissection, or restenosis [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. IVL has recently emerged as a promising adjunctive technology to address these limitations. IVL uses pulsatile sonic pressure waves to fracture both intimal and medial calcium, thereby enhancing vessel compliance while minimizing trauma to the surrounding tissue [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Unlike atherectomy or high-pressure ballooning, IVL preserves the structural integrity of the vessel and does not generate particulate debris, reducing the risk of distal embolization [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eTo date, most of the available data are derived from peripheral and coronary interventions, with large multicenter trials such as the DISRUPT PAD III and CAD III trials demonstrating the safety and efficacy of IVL in treating heavily calcified femoropopliteal and coronary lesions [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. In the latest report from the DISRUPT PAD III trial, IVL treatment of 164 common femoral artery lesions, 95.1% of which had moderate to severe calcification, resulted in a final residual stenosis of 23.6\u0026thinsp;\u0026plusmn;\u0026thinsp;11.5% with no major vascular complications observed by core-laboratory assessment, underscoring its favorable safety profile even in anatomically complex and calcified vascular beds [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eSpecific evidence for IVL in the SMA is currently restricted to isolated case reports. Our findings are consistent with previous reports summarized in the most comprehensive review to date by Spath et al. [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e], who compiled 11 cases involving IVL treatment of severely calcified visceral and renal arteries. The majority of cases (67%) addressed chronic mesenteric ischemia, with the SMA being the most frequently treated vessel [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Across all cases, IVL demonstrated high technical success, with no reported complications such as vessel perforation, distal embolization, or thrombosis. Most procedures involved predilatation followed by IVL and stent implantation, approaches that mirror the technique applied in our case. The number of lithotripsy pulses varied widely (150\u0026ndash;300), and both covered and uncovered stents were used, depending on vessel anatomy and operator preference [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eOur case adds to this evolving body of evidence by demonstrating the successful use of IVL as a preparatory step for stenting in the SMA. Importantly, revascularization with restoration of adequate luminal patency was imperative due to the patient\u0026rsquo;s oncologic status and the anticipated risk of mesenteric hypoperfusion after the planned surgical procedure. IVL facilitated successful low-pressure stent deployment. The use of a 5.5 \u0026times; 60 mm Shockwave\u0026trade; balloon and four cycles of intravascular lithotripsy in our case aligns with the range reported in previously published cases. Notably, this approach enabled the successful deployment of an 8 mm balloon-expandable stent, a diameter rarely achieved in the SMA due to its typically narrow caliber. Spath et al. reported stent implantation with a 7 mm diameter following lesion preparation using an 8 \u0026times; 60 mm IVL balloon. Remarkably, in our case, the deployment of an 8 mm diameter stent was achieved after preparation with a smaller 5.5 \u0026times; 60 mm balloon, representing the largest reported discrepancy between IVL balloon and stent diameter in the current literature. This observation suggests that effective lesion preparation may be achievable even with smaller balloon diameters, underscoring the safety and efficacy of intravascular lithotripsy in addressing the biomechanical challenges posed by dense vascular calcification. By facilitating controlled plaque modification, it enabled the deployment of a larger-diameter stent than it might have been achievable with conventional balloon angioplasty alone.\u003c/p\u003e\u003cp\u003eThis case supports the expanding utility of IVL beyond peripheral and coronary interventions, particularly in anatomically complex vascular territories such as the mesenteric circulation. Despite the encouraging results, the collective experience remains limited to a small number of patients. Future prospective studies are warranted to assess long-term outcomes and better define selection criteria, especially in preoperative settings like ours.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn conclusion, IVL represents a valuable adjunct for lesion preparation in the treatment of heavily calcified SMA stenoses, particularly when optimal stent expansion is required. This technique may be especially beneficial in the preoperative management of oncologic patients undergoing major abdominal surgery, where mesenteric perfusion must be safeguarded. Further prospective studies are necessary to validate long-term outcomes.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eSMA \u0026ndash; Superior mesenteric artery\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;IVL \u0026ndash; Intravascular lithotripsy\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;PTA \u0026ndash; Percutaneous transluminal angioplasty\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;CTA \u0026ndash; Computed tomography angiography\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;CMI \u0026ndash; Chronic mesenteric ischemia\u003c/p\u003e\n"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 declaration of Helsinki.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eWritten informed consent was obtained from the patient for publication of this case report and any accompanying images.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors state that this work has not received any funding.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRobert Terzis\u003c/strong\u003e: Conceptualization, Investigation, Visualization, Writing - Original Draft, Writing - Review \u0026amp; Editing; \u003cstrong\u003eRobert Wawer Matos Reimer\u003c/strong\u003e: Conceptualization, Validation, Writing - Review \u0026amp; Editing; \u003cstrong\u003eDavid Maintz\u003c/strong\u003e: Validation, Writing - Review \u0026amp; Editing, Supervision, Project Administration; \u003cstrong\u003eErkan Celik\u003c/strong\u003e: Conceptualization, Validation, Investigation, Visualization, Writing - Original Draft, Writing - Review \u0026amp; Editing.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eHansen, K.J., et al., \u003cem\u003eMesenteric artery disease in the elderly.\u003c/em\u003e J Vasc Surg, 2004. \u003cstrong\u003e40\u003c/strong\u003e(1): p. 45-52.\u003c/li\u003e\n\u003cli\u003eHuber, T.S., et al., \u003cem\u003eChronic mesenteric ischemia: Clinical practice guidelines from the Society for Vascular Surgery.\u003c/em\u003e J Vasc Surg, 2021. \u003cstrong\u003e73\u003c/strong\u003e(1s): p. 87s-115s.\u003c/li\u003e\n\u003cli\u003eLejay, A., et al., \u003cem\u003eChronic mesenteric ischemia: 20 year experience of open surgical treatment.\u003c/em\u003e Eur J Vasc Endovasc Surg, 2015. \u003cstrong\u003e49\u003c/strong\u003e(5): p. 587-92.\u003c/li\u003e\n\u003cli\u003eTerlouw, L.G., et al., \u003cem\u003eEuropean guidelines on chronic mesenteric ischaemia - joint United European Gastroenterology, European Association for Gastroenterology, Endoscopy and Nutrition, European Society of Gastrointestinal and Abdominal Radiology, Netherlands Association of Hepatogastroenterologists, Hellenic Society of Gastroenterology, Cardiovascular and Interventional Radiological Society of Europe, and Dutch Mesenteric Ischemia Study group clinical guidelines on the diagnosis and treatment of patients with chronic mesenteric ischaemia.\u003c/em\u003e United European Gastroenterol J, 2020. \u003cstrong\u003e8\u003c/strong\u003e(4): p. 371-395.\u003c/li\u003e\n\u003cli\u003eShammas, N.W., et al., \u003cem\u003eIntravascular Lithotripsy for Treatment of Severely Calcified Common Femoral Artery Disease: Results From the Disrupt PAD III Observational Study.\u003c/em\u003e J Endovasc Ther, 2024: p. 15266028241255622.\u003c/li\u003e\n\u003cli\u003eSpath, P., et al., \u003cem\u003eUse of Shockwave Intravascular Lithotripsy in Recanalization of Calcified Visceral and Renal Arteries: A Case Report and Update of the Literature.\u003c/em\u003e J Endovasc Ther, 2024. \u003cstrong\u003e31\u003c/strong\u003e(3): p. 485-490.\u003c/li\u003e\n\u003cli\u003evan Petersen, A.S., et al., \u003cem\u003eOpen or percutaneous revascularization for chronic splanchnic syndrome.\u003c/em\u003e J Vasc Surg, 2010. \u003cstrong\u003e51\u003c/strong\u003e(5): p. 1309-16.\u003c/li\u003e\n\u003cli\u003eBrodmann, M., et al., \u003cem\u003eSafety and Performance of Lithoplasty for Treatment of Calcified Peripheral Artery Lesions.\u003c/em\u003e J Am Coll Cardiol, 2017. \u003cstrong\u003e70\u003c/strong\u003e(7): p. 908-910.\u003c/li\u003e\n\u003cli\u003eBeattie, W.S., et al., \u003cem\u003eSurvival After Isolated Post-Operative Troponin Elevation.\u003c/em\u003e J Am Coll Cardiol, 2017. \u003cstrong\u003e70\u003c/strong\u003e(7): p. 907-908.\u003c/li\u003e\n\u003cli\u003eBrinton, T.J., et al., \u003cem\u003eFeasibility of Shockwave Coronary Intravascular Lithotripsy for the Treatment of Calcified Coronary Stenoses.\u003c/em\u003e Circulation, 2019. \u003cstrong\u003e139\u003c/strong\u003e(6): p. 834-836.\u003c/li\u003e\n\u003cli\u003eAdams, G., et al., \u003cem\u003eIntravascular Lithotripsy for Treatment of Calcified Lower Extremity Arterial Stenosis: Initial Analysis of the Disrupt PAD III Study.\u003c/em\u003e J Endovasc Ther, 2020. \u003cstrong\u003e27\u003c/strong\u003e(3): p. 473-480.\u003c/li\u003e\n\u003cli\u003eBalboa Arregui, O., et al., \u003cem\u003eUse of Shockwave intravascular lithotripsy for the treatment of symptomatic and severely calcified superior mesenteric artery stenosis.\u003c/em\u003e CVIR Endovasc, 2021. \u003cstrong\u003e4\u003c/strong\u003e(1): p. 53.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"cvir-endovascular","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"cire","sideBox":"Learn more about [CVIR Endovascular](https://www.springer.com/journal/42155)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/cire/default.aspx","title":"CVIR Endovascular","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Intravascular lithotripsy, Superior mesenteric artery stenosis, Mesenteric ischemia, Shockwave, Visceral intervention","lastPublishedDoi":"10.21203/rs.3.rs-7515486/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7515486/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eIntravascular lithotripsy (IVL) is an emerging technique for modifying heavily calcified arterial lesions, with primary application in peripheral arteries. We report the use of IVL for lesion preparation prior to stenting in a patient with severely calcified superior mesenteric artery (SMA) stenosis.\u003c/p\u003e\u003ch2\u003eCase Presentation:\u003c/h2\u003e\u003cp\u003eA 66-year-old man with type I adenocarcinoma of the esophagogastric junction (AEG Type I) and neoadjuvant FLOT chemotherapy was scheduled for Ivor Lewis esophagectomy. Preoperative CT angiography revealed a high-grade ostial SMA stenosis due to extensive atherosclerotic calcification. To mitigate the risk of postoperative mesenteric hypoperfusion, percutaneous endovascular revascularization was performed. Following initial predilation, IVL using a Shockwave 5.5 \u0026times; 60 mm balloon catheter was employed for lesion preparation. Subsequently, an 8.0 x 24 mm balloon-expandable stent was successfully deployed with minimal residual stenosis and no complications.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003eThis case demonstrates that IVL represents a feasible and effective adjunct in the management of severely calcified visceral arterial lesions, facilitating adequate lesion preparation and improved stent expansion. IVL may therefore be considered as a therapeutic option in selected patients.\u003c/p\u003e","manuscriptTitle":"Pre-Stenting Lesion Preparation Using Shockwave Intravascular Lithotripsy in Severely Calcified Superior Mesenteric Artery Stenosis","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-15 18:47:04","doi":"10.21203/rs.3.rs-7515486/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"","date":"2025-09-08T05:39:40+00:00","index":0,"fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-09-08T05:36:14+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-09-05T06:23:18+00:00","index":"","fulltext":""},{"type":"submitted","content":"CVIR Endovascular","date":"2025-09-03T09:51:22+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"cvir-endovascular","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"cire","sideBox":"Learn more about [CVIR Endovascular](https://www.springer.com/journal/42155)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/cire/default.aspx","title":"CVIR Endovascular","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"5f7d383f-1517-43b3-baae-9dbdf321f696","owner":[],"postedDate":"September 15th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-01-12T16:05:52+00:00","versionOfRecord":{"articleIdentity":"rs-7515486","link":"https://doi.org/10.1186/s42155-025-00622-2","journal":{"identity":"cvir-endovascular","isVorOnly":false,"title":"CVIR Endovascular"},"publishedOn":"2026-01-07 15:57:28","publishedOnDateReadable":"January 7th, 2026"},"versionCreatedAt":"2025-09-15 18:47:04","video":"","vorDoi":"10.1186/s42155-025-00622-2","vorDoiUrl":"https://doi.org/10.1186/s42155-025-00622-2","workflowStages":[]},"version":"v1","identity":"rs-7515486","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7515486","identity":"rs-7515486","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}