International European Expert Consensus on the Use of Shockwave Intravascular Lithotripsy in Iliac Arteries: A Modified Delphi Study

PURPOSE: To establish pan-European expert consensus on the use of Shockwave intravascular lithotripsy (IVL) for endovascular treatment of calcified iliac steno-occlusive disease and to develop a pragmatic, expert-derived treatment algorithm. MATERIALS AND METHODS: A modified Delphi process comprised an initial workshop, 2 anonymous online surveys and a final workshop. Experts were purposively identified through professional networks using prespecified procedural-volume and IVL-experience criteria. Round 1 combined closed questions with unrestricted free text; thematic and framework analysis informed refinement, separation or removal of candidate items for round 2. Agreement was reported as the proportion supporting each statement, with consensus defined a priori as ≥70%. RESULTS: Twenty-six experts completed round 1 and 17 completed round 2 (65% retention); reasons for non-participation in round 2 were not collected. Vascular surgeons comprised 65% of the round 1 panel, and approximately 65% of participants practised in Italy. Sixteen final statements achieved 73% to 100% agreement. Key items supported computed tomographic angiography with duplex ultrasound (100%), planned rather than bailout IVL use (100%), calcium burden as the principal determinant (93%), and selective rather than routine intravascular imaging (93%). The final workshop approved the algorithm; item-level agreement is displayed within it. CONCLUSION: This modified Delphi study provides a structured expert consensus and algorithm for Shockwave IVL in iliac arteries. It is an expert-opinion framework that should complement, not replace, patient-specific clinical judgement, device instructions for use and local guidance, and it requires prospective external validation.Clinical ImpactThis pan-European modified Delphi study reports expert-agreed statements on planned Shockwave IVL use, imaging, technique, adjunctive treatment and follow-up in calcified iliac disease. The algorithm displays the agreement strength for each recommendation and can support structured multidisciplinary decision-making where comparative evidence is limited. It represents expert opinion rather than a guideline. The algorithm should be applied alongside clinical judgement and device instructions for use. The consensus identified calcium definition, comparative IVL effectiveness assessment, and research priorities in this area.