Intravascular Lithotripsy and the Need for Scaffolding in Isolated Popliteal Lesions

BACKGROUND: To assess the feasibility, safety, and midterm outcomes of intravascular lithotripsy (IVL) in isolated heavily calcified lesions (HCLs) of the popliteal artery, a location historically regarded as a "no-stent zone". METHODS: This retrospective monocentric cohort included 18 consecutive adult patients where IVL was used to treat a symptomatic isolated popliteal HCL-between November 2021 and September 2025. IVL was followed by interwoven stent implantation in case of residual stenosis ≥30%. In other cases, a drug-coated balloon was used. Technical success, primary and assisted patency, target lesion revascularization, and major adverse limb events (MALE) were recorded. Kaplan-Meier survival analysis was provided for patency and reintervention outcomes. RESULTS: Indication was a chronic limb-threatening ischemia in 39% of the cases. The median lesion length was 60 mm (interquartile range [IQR]: 55-100), and 39% were chronic total occlusions. The median degree of stenosis was 90% (IQR: 90-100). The median luminal gain achieved post-IVL was 60%. Bailout stenting was required in 39% of the cases. The technical success rate was 100%. Primary patency was 93% at 12 months and 73% at 24 months. During follow-up, MALE occurred in 22%, including 3 reinterventions that all occurred in patients treated without stenting. At last follow-up, 56% of the patients had received a stent in the target lesion. CONCLUSION: IVL is an effective and safe vessel preparation tool for isolated popliteal HCLs. Since most patients ultimately require stenting the benefit of IVL in a "nothing left behind" strategy remains questionable.