IVL: Calcified Arteries, Antalya | Prof. Dr. Umuttan Doğan

Heavy calcification in the coronary arteries makes it hard for a balloon and a stent to open as far as they should. Treating a calcified artery therefore calls for different preparation from an ordinary stent procedure. IVL (intravascular lithotripsy) is a balloon system that cracks the hard layers of calcium in the artery wall with controlled energy waves. The principle is close to that of breaking kidney stones with sound waves. Once the calcium is cracked, the artery can widen more evenly and the stent can reach the diameter it should.

What Is Calcification in an Artery, and Why Is It a Problem?

Coronary artery disease begins with plaque building up in the wall of the artery. Over the years that plaque hardens and collects calcium within it. In medical language this is coronary artery calcification; in everyday speech, calcium in the arteries.

A calcified plaque is no longer a soft deposit of fat. It is a layer close to bone in hardness, and it stops the wall of the artery from stretching.

Who Gets More Calcification?

Some calcification can be found in anyone, but it increases markedly in certain circumstances:

Older age
Long-standing diabetes
Chronic kidney disease, particularly in people on dialysis
High blood pressure left uncontrolled over a long period
Smoking over many years

Calcification on its own does not call for treatment. The problem arises when heavy calcium sits over a narrowing that does need treating.

Why Is an Ordinary Balloon Not Enough in a Calcified Artery?

In a normal procedure the balloon is inflated, the plaque is pushed aside, the artery widens and the stent is placed. Calcium breaks that chain at three points.

First, the balloon meets resistance. A hard layer of calcium will not let the balloon widen the artery. As the pressure is increased, the balloon expands the softer part where there is no calcium. The artery widens on one side and stays as it was on the calcified side.

Second, the stent does not open fully. For as long as the calcium stays where it is, the stent cannot reach the intended diameter. From the outside a stent has been placed, but inside it is narrower than it should be.

Third, the result may not last. A stent that has not opened fully is one of the commonest reasons for narrowing inside a stent later on.

This is why a calcified artery has to be prepared before a stent goes in.

What Is IVL?

IVL stands for intravascular lithotripsy.

From the outside it looks like an ordinary angioplasty balloon. The difference lies in the small emitters set inside it. These produce short electrical discharges, which turn into pressure waves in the fluid within the balloon.

The waves pass through the wall of the balloon and reach the layer of calcium in the artery wall. Calcium, being hard and brittle, develops micro-cracks under them. The elastic, softer parts of the artery wall are largely unaffected.

One point should be said plainly: IVL does not take the place of a stent. It is a step that prepares the artery for one.

How Does IVL Work?

You may have heard of breaking kidney stones. There too, sound waves break up the stone without harming the soft tissue around it. IVL uses the same physical principle inside the artery, on a far smaller scale.

It goes like this:

The balloon is placed at the calcified segment and inflated at low pressure. The aim is not to force the artery but to bring the balloon into contact with the wall.
The emitters send out energy waves in succession. Each run lasts a few seconds.
The waves crack not only the calcium at the surface but calcium reaching deep into the artery wall as well. This is what sets IVL apart from methods that work only on the surface.
Once the calcium is cracked, the artery regains some of its ability to stretch.
The balloon is then inflated at normal pressure and, where needed, a stent is placed.

There is a detail worth noting: IVL does not remove the calcium. It stays where it is and is only cracked. The aim is not to get rid of the calcium but to let the artery widen.

How Do You Prepare?

A planned procedure for a calcified artery is not very different, in terms of preparation, from an ordinary angiogram. A few points still matter.

A full list of your medicines: bring everything you take in writing, with the doses — blood thinners, diabetes medicines and herbal supplements included.
Your kidney results: contrast dye is used during the procedure. Your kidney function is assessed beforehand and fluids are planned in advance if needed.
Diabetes medicines: some may need to be stopped for a short period around the procedure. Do not decide that yourself; ask your doctor.
Any history of allergy: always say if you have reacted to contrast dye or to any medicine before.
Fasting: you will be asked not to eat for a certain period beforehand. The team doing the procedure will tell you how long.
Your earlier tests: if you have had an angiogram before, bring the images and reports with you. Seeing how the calcification has changed over time helps with the planning.

Before the procedure you are told what will be done and your written consent is taken. If there is anything you do not follow, do ask.

How Is IVL Carried Out?

IVL is not a separate operation. It is done during a coronary procedure, through the same access point as the angiogram.

Access. Under local anaesthetic, the artery is entered at the wrist (the radial route) or at the groin.
Assessing the artery. Where the calcium is, how widespread it is and how deep it lies are examined with imaging.
Placing the balloon. The IVL balloon is advanced to the calcified segment and inflated at low pressure.
Delivering the energy. Waves are given in runs of a few seconds. A run is repeated if needed.
Widening. The balloon is inflated at normal pressure to open the artery.
The stent. Where suitable, a stent is placed in the same session and checked to make sure it has opened fully.

You are awake throughout. No general anaesthetic is needed.

What Will You Feel?

You will not feel the catheter and the balloon moving inside the artery; there are no pain-sensing nerve endings inside blood vessels.

While the energy waves are being delivered, some people describe a mild pressure or a buzzing feeling in the chest. As the balloon is inflated there may be brief chest discomfort, just as in an ordinary balloon procedure, passing once it is let down. Do tell the team if you are uncomfortable.

How Long Does It Take?

IVL usually adds a few minutes to a standard stent procedure. The total time depends on how widespread the calcification is, how many arteries are being treated and whether another method is also needed. It would not be right to give a firm figure; you will be told what to expect in your own case.

How Do IVL and Rotational Atherectomy Differ?

There are two main approaches to a calcified artery, and they work in fundamentally different ways.

Rotational atherectomy (rotablation): a small, diamond-tipped burr spinning at very high speed grinds the calcium away. What is removed enters the bloodstream as microscopic particles and is cleared by the body. It thins the calcium at the surface.
IVL: nothing is ground away. The calcium is left where it is and cracked with pressure waves. It can also reach calcium deep in the artery wall.

They are not rivals. One suits some arteries, the other suits others, and sometimes both are used together.

How Is the Method Chosen?

The choice follows where the calcium is, how deep it lies, how long the narrowing is and how wide the artery is. There is a detail here that matters in practice and is rarely mentioned: the IVL balloon has to be able to cross the narrowing. If the narrowing is too tight for the balloon to pass, the artery may need opening by another method first.

The decision is therefore not made at a desk from the angiogram picture. The real structure of the artery is assessed during the procedure.

The Part Imaging Plays

An angiogram shows calcium only to a limited extent. It does not show where in the wall the calcium sits, how deep it goes or how thick it is.

IVUS (intravascular ultrasound) comes in here. By taking cross-sections from inside the artery, it maps the calcium. Three questions can then be answered before the procedure: is the calcium at the surface or deep? What is the true diameter of the artery? Which method of preparation is needed?

At the end of the procedure, the same imaging shows whether the stent has really opened fully. International cardiology guidelines recommend using intravascular imaging in complex, calcified procedures.

Whether the narrowing is genuinely restricting blood flow is a separate question, assessed with FFR.

Who Is IVL For?

IVL is not used in every stent procedure. It comes into play where calcification makes the procedure difficult:

Narrowings with marked calcification on the angiogram or on imaging
Cases where an ordinary balloon cannot widen the artery enough
Arteries that feed a large area of muscle and leave little margin for error, such as the left main coronary artery
Calcium behind a stent placed earlier that never opened fully
Calcified narrowings at the mouth of an artery
Preparing the calcified segment during completely blocked artery (CTO) procedures

When IVL Is Not Suitable

IVL is not used in every calcified artery:

Where the calcification is mild and an ordinary balloon is enough, no additional method is needed.
IVL balloons are made for particular vessel diameters. In very small arteries a suitable size may not exist.
If the balloon cannot cross the narrowing, another method of preparation is needed first.
Where the narrowing does not call for treatment at all, calcification on its own is not a reason to operate.

Whether it suits you is decided by assessing the structure of the artery together with your existing test results.

Stent or Bypass in a Calcified Artery?

This is what patients most often ask once heavy calcification has been found. The answer does not rest on one measure.

The following are weighed together:

How many arteries are involved and where the narrowings are
Whether the left main coronary artery is part of it
Whether there is diabetes
The pumping function of the heart
Kidney function and other conditions
Whether the artery can be prepared properly by catheter

In complicated cases this assessment is not made by one doctor but through a process in which cardiology and cardiac surgery give their views together. Your own preference is part of that process.

What IVL changes in this picture is the following: some arteries that were once considered difficult to prepare by catheter purely because of calcification can be prepared today, in suitable patients. That does not mean a stent can be chosen for every patient; it changes the measures on which the decision is made.

What Are the Possible Risks?

Treating a calcified artery is an interventional procedure and, like every interventional procedure, carries certain risks. Knowing them lets you ask the right questions beforehand.

Things that can happen in coronary procedures generally:

Bruising, bleeding or swelling at the access site
An allergic reaction to the contrast dye, or a temporary effect on kidney function
Injury to the wall of the artery; rarely, a tear
Changes in rhythm during the procedure
Narrowing developing again later where the stent was placed

Particular to IVL, brief irregularities in the heartbeat can appear while the energy waves are being delivered. These usually settle on their own, and your rhythm is monitored continuously throughout.

The point of this list is to inform rather than to alarm. What the risks mean in your situation is discussed in detail at the consultation beforehand, and the consent process covers it.

Afterwards

Follow-up after a procedure involving IVL runs within the same framework as after a standard stent procedure.

The access site (wrist or groin) is watched for a period.
If a stent was placed, blood-thinning medicines are taken regularly for the period your doctor sets. It is important not to stop them on your own.
Cholesterol, blood pressure and blood sugar continue to be managed. The process underlying the calcification does not end with the procedure.
Smoking is stopped.
Cardiology review is carried out at set intervals.

If you notice a change such as chest pain, breathlessness or swelling at the access site, see your doctor without waiting.

Treatment for Calcified Arteries in Antalya

Prof. Dr. Umuttan Doğan is a cardiologist working in complex coronary artery procedures. IVL is carried out in the catheter laboratory at Antalya American Hospital, in the same session as the coronary procedure.

If you have had an angiogram and been told there is heavy calcification in your arteries, or you are having a problem with a stent that was placed, you can be seen at the clinic in Konyaaltı with the images and results you already have. You will find his background and contact details on their own pages.

Frequently Asked Questions

Will IVL hurt?

You will not feel the catheter moving. While the energy waves are delivered there may be a mild pressure or buzzing feeling in the chest. Brief chest discomfort can occur as the balloon is inflated and passes once it is let down. Local anaesthetic is used at the access site.

Does IVL take the place of a stent?

No. IVL is a method of preparation. By cracking the calcium it lets the artery widen; the narrowing itself is usually then treated with a balloon and a stent.

Is IVL the same as breaking a kidney stone?

The physical principle is similar: in both, pressure waves crack a hard structure and largely spare the soft tissue around it. The application is entirely different. For a kidney stone the waves are delivered from outside the body; in IVL they come from a balloon placed inside the artery itself.

Does the procedure get rid of the calcium completely?

No. IVL does not remove the calcium from the artery; it only cracks it. The aim is to let the artery widen and the stent open fully. Because the process that causes calcification carries on, medication and control of the risk factors continue after the procedure.

Is IVL done in the same session as the angiogram?

Yes. IVL is not a separate procedure or an operation; it is carried out during the coronary procedure, through the same access point. You do not need to come back a second time.

The information on this page is for general guidance and does not replace a consultation. Decisions about diagnosis and treatment are made by your doctor after assessing your own situation.