Shockwave Intravascular Lithotripsy Use in the Femoro-Popliteal Segment: Considerations From an Expert Pan-European Panel Regarding Best-Care Practice

Purpose: Produce expert recommendations regarding the optimal use of Shockwave intravascular lithotripsy (IVL) when treating femoro-popliteal steno-occlusive peripheral artery disease (PAD), guiding operators to use Shockwave IVL. Materials and Methods: A modified 3-step Delphi process was used to gain consensus surrounding preoperative/intraoperative/postoperative considerations when using Shockwave IVL for femoro-popliteal PAD. This included a structured survey, focus-group (with qualitative thematic analysis of views expressed), and final confirmatory round; participants were recruited across Europe including the United Kingdom/Switzerland. Results: Following a review to inform an online survey, 25 experts took part in a survey (5 European countries, 2023), followed by a focus-group (15 participants), 9 interviews, and final confirmatory round. A list of recommendations was prepared where at least moderate-level or high-level agreement was reached (≥70% participants agreeing). The recommendations relate to the optimal preoperative imaging, preoperative preparation(s), intraoperative imaging and use of adjuncts, as well as postoperative course, when using Shockwave IVL. Conclusion: A list of expert recommendations is provided guiding the optimal use of Shockwave IVL in femoro-popliteal PAD. This will help operators achieve better clinical outcomes. Clinical Impact This pan-European panel of experts using intravascular lithotripsy in routine peripheral arterial disease endovascular practice has provided important insights into best care practices before, during, and after such procedures. Several recommendations have been produced based on a structured consensus process to guide clinicians globally. This will improve and standardise the use of this technology in the femoro-popliteal arterial segment.