Introduced in 2009, transcarotid artery revascularization (TCAR) with flow reversal offers a less invasive option for carotid revascularization in high-risk surgical patients. In comparing in-hospital outcomes, TCAR had stroke/death/myocardial infarction rates similar to those of open CEA despite older and substantially higher risk patients (Schermerhorn et al, 2020). Compared with transfemoral stenting, TCAR had significantly lower in-hospital TIA/stroke/death rates despite a population with significantly more comorbidities (Malas et al, 2019). A relative contraindication to use of TCAR and carotid stenting in general is heavily calcified target lesions and lesions with circumferential calcification. Intravascular lithotripsy (IVL) has been introduced and approved for use in coronary artery and lower extremity arterial disease for endovascular treatment of heavily calcified lesions. IVL generates a sonic pressure wave that interacts with calcium, creating sheer stress that fractures the calcium. The objective of the study was to apply IVL to heavily calcified carotid lesions undergoing treatment with TCAR in high-risk surgery patients. This study represents a multicenter case series of seven patients undergoing TCAR with circumferential calcification of the target lesion. Treatment included off-label/off-instructions for use predilation or postdilation using IVL. Patients treated were considered high risk for carotid endarterectomy secondary to medical comorbidities in all cases. The primary end point was procedural success plus the absence of stroke in the immediate and 30-day postoperative period. The secondary end point was an improvement in the target lesion stenosis by North American Symptomatic Carotid Endarterectomy Trial (NASCET) criteria and nonsignificant (<50%) residual stenosis on follow-up imaging. Technical success was achieved in all cases. No patient suffered a stroke in the immediate or 30-day postoperative period. No cranial nerve abnormality, hematoma, wound infection, or other procedural complications was reported in the immediate postoperative period or at the first follow-up visit. By NASCET criteria, all patients had improvement in the target lesion stenosis, with all having nonsignificant stenosis on follow-up imaging. Dilation with IVL during TCAR is shown herein to be applicable safely without neurologic consequence in seven patients and has proved to be a technically feasible option in patients with extensive calcification of the target lesion. A larger study is needed to confirm the safety of applying IVL in the carotid vasculature in conjunction with TCAR. and longer follow-up data are needed to confirm the durability of these early results. The addition of IVL appears to increase the applicability of TCAR to highly calcified lesions and may offer expansion of indications for carotid stenting.