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BackTable / VI / Podcast / Episode #172

Treating Above the Knee Calcium

with Dr. Bryan Fisher and Dr. Sabeen Dhand

CLI fighters Dr. Bryan Fisher and Dr. Sabeen Dhand discuss their approach to treating calcified arteries above the knee, including looking at newer technologies and choosing the appropriate device to effect real durable change to the calcified wall.

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Shockwave Medical

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Treating Above the Knee Calcium with Dr. Bryan Fisher and Dr. Sabeen Dhand on the BackTable VI Podcast)
Ep 172 Treating Above the Knee Calcium with Dr. Bryan Fisher and Dr. Sabeen Dhand
00:00 / 01:04

BackTable, LLC (Producer). (2021, December 13). Ep. 172 – Treating Above the Knee Calcium [Audio podcast]. Retrieved from

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Podcast Contributors

Dr. Bryan Fisher discusses Treating Above the Knee Calcium on the BackTable 172 Podcast

Dr. Bryan Fisher

Doctor Bryan T. Fisher Sr. is a practicing Vascular Surgeon and the Chief of Vascular Surgery at Tristar Centennial Medical Center in Nashville, TN.

Dr. Sabeen Dhand discusses Treating Above the Knee Calcium on the BackTable 172 Podcast

Dr. Sabeen Dhand

Dr. Sabeen Dhand is a practicing interventional radiologist with PIH Health in Los Angeles.

Show Notes

In this episode, vascular surgeon Dr. Bryan Fisher and our host Dr. Sabeen Dhand discuss treatments, intravascular ultrasound (IVUS), and device selection for calcified lesions above the knee.

First, Dr. Fisher discusses common risk factors for above the knee calcifications, including diabetes, end-stage renal disease, and smoking. In his diagnostic workup, he highlights the benefits of using CT for showing atherosclerotic disease, as well as IVUS for viewing intimal and medial calcifications.

With intimal calcifications, Dr. Fisher prefers to use an atherectomy device. For severely stenotic regions, he notes that orbital atherectomy can clear the way for other devices to pass through. After atherectomy, he usually performs IVUS to identify the luminal gain and assess the degree of plaque modification.

The doctors talk about new frontiers in technology such as intravascular lithotripsy, a technique that has been modified from urological treatment. The intermittent delivery of focal energy cracks calcium deposits and minimizes the risk of vessel rupture. Additionally, they discuss optical coherence tomography and how it can assist in visualizing the results of lithotripsy.

Overall, Dr. Fisher believes that angioplasties will likely cause injury to intimal walls, but these effects can be minimized by knowledge of vessel architecture and proper device selection.


Transcript Preview

[Dr. Sabeen Dhand]:
Very cool. I like it. Okay. So now you cross and I use IVUS and we've kind of talked about atherectomy for intimal calcifications. Is there any kind of specific device or type of device that you like for a calcified intimal lesion?

[Dr. Bryan Fisher]:
That's a great question. For a really heavily calcified disease where I can't get devices to track through, so we often run into the problem with getting a balloon or some sort of definitive treatment through the lesion because of that heavily calcified disease. There are a couple of devices that I like to use. Orbital atherectomy works well in this case in that you can kind of create that bird hole through the area and allow other devices to track through. I found that laser surprisingly works. It works in a decent manner in getting through those lesions and being able to provide a definitive care. I don't have much experience with directional atherectomy in my practice, and I'm learning some newer technologies that may offer some help. But heavily calcified disease is really kind of the last frontier and really the thing that we're working so hard to be able to conquer because it makes these cases so much more difficult.

Dr. Fisher is a paid consultant for Shockwave Medical and opinions expressed are those of the speaker and not necessarily those of Shockwave Medical.

In the United States: Rx only.

Indications for Use—The Shockwave Medical Intravascular Lithotripsy (IVL) System is intended for lithotripsy-enhanced balloon dilatation of lesions, including calcified lesions, in the peripheral vasculature, including the iliac, femoral, ilio-femoral, popliteal, infra-popliteal, and renal arteries. Not for use in the coronary or cerebral vasculature.

Contraindications—Do not use if unable to pass 0.014 guidewire across the lesion—Not intended for treatment of in-stent restenosis or in coronary, carotid, or cerebrovascular arteries.

Warnings—Only to be used by physicians who are familiar with interventional vascular procedures—Physicians must be trained prior to use of the device—Use the generator in accordance with recommended settings as
stated in the Operator’s Manual.

Precautions—use only the recommended balloon inflation medium—Appropriate anticoagulant therapy should be administered by the physician—Decision regarding use of distal protection should be made based on physician assessment of treatment lesion morphology.

Adverse effects–Possible adverse effects consistent with standard angioplasty include – Access site complications – Allergy to contrast or blood thinner – Arterial bypass surgery — Bleeding complications — Death — Fracture of guidewire or device — Hypertension/Hypotension — Infection/sepsis — Placement of a stent — renal failure — Shock/pulmonary edema — target vessel stenosis or occlusion — Vascular complications. Risks unique to the device and its use — Allergy to catheter material(s) — Device malfunction or failure — Excess heat at target site.

Prior to use, please reference the Instructions for Use for more information on indications, contraindications, warnings, precautions and adverse events.

Please contact your local Shockwave representative for specific country availability and refer to the Shockwave S4 and Shockwave M5 instructions for use containing important safety information.

Disclaimer: The Materials available on are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.

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Calcified popliteal occlusion treated with 5mm Shockwave lithotripsy

Shockwave Intravascular Lithotripsy Treatment Algorithm & Technical Success

Intravascular ultrasound image of intima, media, and adventitia.

Using IVUS to Guide Treatment of Calcified Vessels with Intravascular Lithotripsy


Arterial Revascularization Procedure Prep
Atherectomy Procedure Prep
Critical Limb Ischemia (CLI) Condition Overview
Intravascular Lithotripsy Procedure Prep
Intravascular Ultrasound (IVUS) Procedure Prep
Peripheral Artery Disease Condition Overview

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