An 88-year-old man with diabetes mellitus presented with intermittent claudication (IC) of his right leg (Rutherford category III). His ankle brachial index (ABI) was 0.79 on the right side and 1.13 on the left side. Angiography revealed severe calcified stenosis in the CFA involving the proximal superior femoral artery (SFA) and the deep femoral artery (DFA) (Fig. 1A). Elective EVT for this severely calcified CFA lesion was selected to relieve symptoms.
A 6-French guiding sheath (Destination, Terumo Interventional System, Somerset, NJ, USA) was inserted via the contralateral approach. A 0.014-inch polymer jacket wire (Cruise, Asahi Intecc, Nagoya, Japan) was advanced into the DFA, and a tapered 45 g 0.014-inch wire (Jupitar Max, Boston Scientific, Natick, MA) was passed into the SFA using a double lumen catheter (Crusade; Kaneka, Osaka, Japan) (Fig. 1B). A Crosser® catheter (FlowCardia Inc., Sunnyvale, CA, USA) was passed six times into the direction of the SFA, and the lumen was expanded with a 3 × 40 mm scoring balloon at 10 atm (NSE PTA; Nipro, Osaka, Japan) (Fig. 1C). Angiography showed insufficient lumen gain, and intravascular ultrasound (IVUS; Vision PV, Philips, Amsterdam, Holland) showed the wire route was at the edge of the vessel. Therefore, the Crosser and balloon dilatation procedures were not satisfactory (Fig. 1D). We unsuccessfully attempted to advance the guidewire into the center of the calcified plaque antegradely with a tapered 40-g 0.014-inch wire (VASSALLO 40, Filmeck, Nagoya, Japan). Given the severe calcification, we decided to make a direct puncture into the plaque using an inner cylinder of a 15-cm 20G long needle (introducer needle, Medikit, Tokyo, Japan). A 6-French sheath (Terumo Interventional System, Somerset, NJ, USA) was inserted retrogradely into the proximal SFA. After the needle was inserted through the sheath, we confirmed that the needle tip was facing the center of the calcified plaque from two directions (LAO30, RAO30) (Fig. 2-A and -B). We picked the calcified plaque with the needle to create a new route with gentle rotation. Then, while checking the silhouette of calcification from multiple directions, we introduced a tapered 40-g 0.014-inch wire (VASSALLO 40, Filmeck, Nagoya, Japan) through this needle. The wire was advanced relatively easily. Subsequently, a pull-throw guidewire position was established. Crosser was performed from an antegrade sheath. We confirmed that the guidewire had passed through the calcification using IVUS (Fig. 2-C1).
A kissing balloon dilatation was performed with a 10 × 40 mm scoring balloon (NSE PTA; Nipro, Osaka, Japan) on the SFA, and a 6 × 40 mm semi-compliant balloon (Sterling; Boston Scientific, Natick, MA) on the DFA (Fig. 2-D). The final angiogram showed that the stenosis still remained, but the blood flow was improved significantly, whereas IVUS showed a sufficient lumen area of 15.2 mm2 (Fig. 2-E②).
After the procedure, SFA sheath was removed. Hemostasis was achieved by manual compression and 6 × 40 mm semi-compliant balloon inflation at the puncture side.
IC was completely alleviated, and ABI was improved to 0.95 on the right side. At the 8-month follow-up, ABI remained stable, at 0.92 on the right side, without any other symptoms.