Transcription:

Prakash Chandran: As we grow older, our heart has to work harder. It's a common adage, but what are some of the reasons? Well, usually calcification occurs in the heart valves and arteries with age and with lifestyle factors such as smoking. But when an issue arises, however, stents are often used to keep the blood flowing.

What if there was a procedure that could make that process easier and more effective? Here to talk to us about shockwave intravascular lithotripsy is Dr. Edward Wingfield. He's the Medical Director of St. Francis Medical Center Vascular Lab and interventional cardiologist with Hamilton Cardiology Associates.

This is Word On Wellness, the podcast from St. Francis Medical Center. My name is Prakash Chandran. So Dr. Wingfield, thank you so much for being here. I really appreciate your time. Shockwave intravascular lithotripsy, it sounds like something out of a science fiction movie. Could you talk to us more specifically about what it is and when it's used?

Edward Wingfield, MD: Oh, absolutely. Thank you so much, Prakash. Thank you for having me. Pretty excited about just giving a little bit more information about the amazing technology that we have at our disposal here at St. Francis. And what shockwave lithotripsy is, essentially you alluded to it earlier on in the intro. What happens over time with blood vessels is those vessels can harden and we've all heard of hardening of the arteries, but the cholesterol that deposits within the arteries tends to harden and becomes almost like a rock-like substance in some patients and that rock-like substance causes significant blockages. And these blockages result in chest pain, can result in heart attack, obstruction of blood flow, not only to the heart, but to the legs and the lower extremities and place some patients at risk of amputations and things of that nature.

So what shockwave lithotripsy is essentially it is a interventional device that we use to literally break up the hardened plaque within the arteries. We use a tiny balloon that delivers ultrasound waves into the hard plaque, if that makes sense. But these ultrasound waves were previously used, most of us are familiar with kidney stones, and patients who have renal stones and kidney stones can be a big problem. And one of the ways to break up these hardened kidney stones is to use the same technology we now use in the heart, but for years, they used in the kidney. And the lithotripsy, which it's called, is when you deliver ultrasound waves to kidney stones and breaks up and pulverizes these stones. Well, they use that technology or transferred that same technology to the heart and the extremities. And we use tiny balloons that are coiled with ultrasound-dispersing coils that emit an ultrasound signal that actually cracks the plaque and softens the artery so that we can successfully deliver stents and open the arteries and restore blood flow.

Prakash Chandran: Yeah, that sounds absolutely amazing. And before this existed, what was the traditional way to, for example, break up calcium or the plaque or was that even possible?

Edward Wingfield, MD: Well, we had techniques to make that possible, although the risk to the patient was much higher. This is a much lower risk procedure. And, you know, traditional attempts or traditional ways of opening calcified arteries, I guess, most patients are used to hearing the word roto-rooter. We have a device that basically roto-rooters out the hard plaque. But when you roto-rooter the artery, you do induce some sort of mechanical trauma to the artery. In some cases, patients may have issues with blood pressure or their heart rate may slow down. So this was the traditional rotational atherectomy is what we called it. We called it Rotablator. And Rotablator is still very successful and we still use it a great deal to open up very hardened plaques. It is somewhat cumbersome. There is a bit more risk involved, although extremely successful. So if we had to do a Rotablator procedure on a patient tomorrow, that procedure would go well. But the thing about using the shockwave technology, you can get the same results with much less of the risk and much less of the additional requirements that go along with doing a roto-rooter kind of rotational atherectomy procedure.

Prakash Chandran: Yeah, I was just going to ask you when should a patient or care provider consider this shockwave procedure over the more traditional Rotablator procedure that you described?

Edward Wingfield, MD: Yeah. There are different scenarios, but I would say in most cases where you're considering using rotational atherectomy or the Rotablator system, you're able to use the shockwave technology. So you would certainly choose the shockwave technology. And since we've been using it, in fact, I mean, I've been using it in the lower extremities and the legs for, well, in 2016, 2017. So it's been quite some time we've been successfully using it in hard plaques down in the lower extremities. It was recently approved for the heart arteries. So with the use that we've had, it's been extremely successful. So I would say 95% of the procedures where we were previously doing rotation atherectomy, we can now do shockwave. There are isolated and some select cases, and that would be determined by the interventional cardiologist who's doing the procedure in terms of what route to go. Do you need the traditional roto or can we go with shockwave?

Prakash Chandran: So are there ever cases where the lithotripsy is not recommended?

Edward Wingfield, MD: No, the only issue sometimes is deliverability, okay? Some arteries can be 99.9% occluded and blocked. And if that artery is blocked to that extent, sometimes you can't deliver a shockwave balloon through that tight blockage. So that's been the limitation that we've seen. But as I said, 95% of the time, we successfully are able to use a shockwave and in a small percentage of cases, typically because of how significant the blockage is, you may have to use different means.

Prakash Chandran: So what are the success rates that we're seeing with this shockwave technology in conjunction with stent implementation?

Edward Wingfield, MD: Right. Well, in the studies that were looked at with shockwave in the coronary arteries, in the heart you know, a lot of their data was 30-day data. And in the cases that were done, we're talking 400 plus cases that were, I guess, enrolled in their study or that were looked at, at least 92% of those patients who had a shockwave procedure, we were able to deliver stents, okay? So when you're using shockwave, these are some of the toughest, you know, the hardest lesions or blockages to fix. So you've got a 92% success rate, where we were able to use the shockwave and successfully deliver a stent. And then even the one-year outcome data is very robust and very strong. So, the patients who did well without having a repeat procedure or heart attack was extremely low and the data was extremely strong. So, the data to support use of the shockwave device in stent delivery, as well as at least one year in long-term outcomes have been very strong.

Prakash Chandran: Talk to us a little bit about the procedure itself. Like, what is it like? Is it invasive? And maybe talk to us about the recovery time as well.

Edward Wingfield, MD: Yeah. Well, it's minimally invasive. So although we're talking about shockwave, it's only one component of the procedure and the bigger procedure, a bigger picture is the coronary angiogram and angioplasty. So this is where we're talking about a heart catheterization or cardiac cath. So patient goes for a cardiac catheterization. We want to look at the artery to determine if there's a blockage. If there's a blockage, then we want to fix it because this patient is having symptoms.

So with that, typically, the patient comes to St. Francis Medical Center, get checked in. He or she is brought to the cardiac catheterization lab. The patient for the procedure typically receives some sedation, okay? So it's kind of twilight and the patient's relaxed and comfortable. And over 80% of our cases, we do radial artery access, that means we access the artery through the arm or through the wrist. That makes it a much easier procedure for the patient. The recovery time is much easier. Most patients even go home following the procedure because of the access from the radial artery or the wrist.

So a catheter is inserted into the artery in the arm. That catheter, actually, we're able to direct that catheter into the arteries of the heart. And through that catheter, we're able to inject contrast or IV dye so that the arteries light up, we take x-ray pictures of the heart and we're able to see the blockages. Once we see the blockage, we can then direct a balloon or a shockwave balloon to the blockage and that balloon emits ultrasound waves at the precise location where the blockage is. That will soften and break up the plaque causing no harm to the patient. Some patients they say, "Well, what happens when you break up the plaque?" Well, we're causing very micro-- they're called micro fissures, very small cracks in the plaque that soften the plaque, and that makes it easier for us to deliver a stent. From there, we deliver a stent and place a stent inside of the artery. So this procedure probably takes about 45 minutes to an hour. After the stent is delivered, we confirm that the stent is delivered. We take pictures to show delivery and outcome. Following our final pictures, the patient goes to recovery. You're in recovery for about two hours. But once the patient's done with the procedure, patients tend to eat after the procedure. We make calls to the family to let them know the results of the procedure and the patient would go home later that day in a lot of cases. Some cases may stay overnight depending. That's essentially the day of heart catheterization with lithoplasty.

Prakash Chandran: Yeah, it's amazing. So this might be an oversimplification, but typically you would go in for an angiogram or an angioplasty. And they would, you know, do the ink and they would see if there was an area that was available to use a stent. But with this new lithotripsy technology, it basically opens up or broadens the amount of times that you are able to use a stent and things don't have to go to more invasive procedures. Is that more or less correct?

Edward Wingfield, MD: No. That's exactly correct. I mean, the only thing I would add to that is that, yeah, these stents are-- they're metal, it's a metal scaffold. So you're trying to deliver a metal scaffold into a calcified or hard artery and that can be difficult. So, you know, you're trying to shove a stent into a hard artery, that can be difficult. So you soften the plaque, you deliver the stent, the stent expands and it covers the area of disease. And it's minimal trauma to the patient compared to the other alternatives that we previously used. So this is groundbreaking technology and there's nothing else like it, I'll be honest.

Prakash Chandran: Yeah, no question about it. Well, this has been a fascinating conversation, Dr. Wingfield. Is there anything else you'd like to share with our audience today?

Edward Wingfield, MD: I guess there was a press release that St. Francis was one of the first or the first in this region to use shockwave, we had patients who would call and say, "Am I going to get the shockwave? Am I going to get the shockwave? Can we do shockwave?" So, case by case basis. And that's the thing. Not all patients fit the criteria for shockwave, but it is a decision that's made at the time of the procedure. And the patient would be advised that this is best case for the best outcome using shockwave in this case. So, maybe 10% of the time, maybe 15%, 20% of cases would require shockwave. But for those select patients who need it or fit that criteria, it's excellent therapy.

Prakash Chandran: Well again, thank you so much for your time, Dr. Wingfield. I truly appreciate it.

Edward Wingfield, MD: You're welcome. Thank you so much for having me. I really appreciate it.

Prakash Chandran: That was Dr. Edward Wingfield, Medical Director of St. Francis Medical Center Vascular Lab and interventional cardiologist with Hamilton Cardiology Associates. Please visit stfrancismedical.org or hcahamilton.com to learn more. If you found this podcast to be helpful, please share it on your social channels and be sure to check out the entire podcast library for topics of to you.

Thanks again for listening to Word On Wellness, the podcast from St. Francis Medical Center. My name is Prakash Chandran, and we'll talk next time.