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BackTable / VI / Podcast / Episode #175

Treating Below the Knee Calcium

with Dr. Kumar Madassery and Dr. Sabeen Dhand

CLI fighters Dr. Kumar Madassery and Dr. Sabeen Dhand discuss their approach to treating calcified arteries below 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 Below the Knee Calcium with Dr. Kumar Madassery and Dr. Sabeen Dhand on the BackTable VI Podcast)
Ep 175 Treating Below the Knee Calcium with Dr. Kumar Madassery and Dr. Sabeen Dhand
00:00 / 01:04

BackTable, LLC (Producer). (2021, December 27). Ep. 175 – Treating Below the Knee Calcium [Audio podcast]. Retrieved from

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Podcast Contributors

Dr. Kumar Madassery discusses Treating Below the Knee Calcium on the BackTable 175 Podcast

Dr. Kumar Madassery

Dr. Kumar Madassery is a practicing interventional radiologist with Rush University in Chicago.

Dr. Sabeen Dhand discusses Treating Below the Knee Calcium on the BackTable 175 Podcast

Dr. Sabeen Dhand

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


In this episode, interventional radiologist Dr. Kumar Madassery and our host Dr. Sabeen Dhand discuss atherosclerosis in tibial vessels below the knee and devices for atherectomy, angioplasty, and dissection repair.

While non-invasive imaging for calcium is still lacking, Dr. Madassery encourages operators to look for calcium on X-ray and ultrasound. He believes that visualization with ultrasound will improve if there is greater collaboration and standardization across all operators. Next, Dr. Madassery differentiates between intimal and medial calcifications. He notes that medial calcifications usually present as “railroad tracks” in diabetic and end-stage renal failure patients, while intimal calcifications lead to plaque ruptures. Each type is distinguishable with the use of intravascular ultrasound (IVUS).

Dr. Madassery walks through his approach to calcified lesions. He says that using angiogram to identify whether a lesion is stenotic or occlusive is a crucial first step. He also emphasizes the importance of having a wire escalation strategy. The doctors highlight orbital and laser atherectomy, scoring balloons, and intravascular lithotripsy (IVL).

Finally, Dr. Madassery describes his perspective on arterial dissection, a common complication of balloon angioplasty. The decision to treat dissections is dependent on the operator, but he gives advice on weighing the pros and cons of treating. He speaks about the advantages of using the self-expanding Tack system to stent only specific problematic regions.

Dr. Madassery 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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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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