Severe symptomatic carotid artery stenosis poses a significant risk for recurrent strokes. Best treatment options depend on multiple factors, including patient medical conditions and lesion characteristics. ¹ Despite treatment options such as carotid endarterectomy, conventional carotid angioplasty/stent, and transcervical carotid revascularization, certain patients are not ideal candidates for any of these modalities. Novel technical advances such as intravascular lithotripsy (Shockwave Medical Inc.) have emerged as a potential treatment modality to treat patients with severely calcified plaques, a well-described limitation for carotid stent expansion and apposition. ^2-4 The safety and efficacy of intravascular lithotripsy have been demonstrated through select case series and coronary artery disease I‐II‐III studies, culminating in its Food and Drug Administration approval for the management of novo, calcified, stenotic coronary arteries before stent placement. ^2,5 This technical video presents an illustrative case of a patient with symptomatic severely calcified carotid plaque with previous neck radiation precluding endarterectomy, treated with off-label use of balloon lithotripsy plus stent. ⁶ The patient consented to the procedure.