PMC6349981_01
Digital subtraction angiography (DSA) and duplex ultrasound (DUS) images of the right SFA. (a) DSA confirmed an occlusion of more than 25 cm of the right SFA. (b) Attempts to cross the occlusion via an antegrade access remained without any success. (c) Therefore, a retrograde access via the anterior tibial artery was chosen and a wire was brought across the occlusion. The recanalization was performed using a rotational atherectomy device and DCBs without concomitant stent implantation. (d) Final angiography with complete revascularization of the SFA. (e, f) Doppler ultrasound performed at 3 months after the initial procedure confirmed a complete recanalization of the right SFA without evidence of a remaining stenosis.
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Angiography revealed a long chronic total occlusion (CTO, TASC D) of the SFA (Figure 1(a)), notably without proximal stump. Terumo) and a 0.18 wire (V18; Boston Scientific) (Figure 1(b)). Thus, a retrograde approach via the anterior tibial artery was elected and performed with a micropuncture set (Micropuncture Pedal Introducer; Cook Medical) under ultrasound guidance with the patient in supine position. Terumo) recanalization succeeded with guide wire entry in the CFA (Figure 1(c)) and externalized to the left CFA. The CTO was then treated through the antegrade approach using a filterless rotational atherectomy device (Rotarexs; Straub Medical) due to severe calcifications (PACSS 4c) and multiple dilations of the entire SFA (3*120 and 4*120; Admiral Medtronic, 180-s inflation time each). Final angiography showed only minor non-limiting dissections and thus a stent-free approach with drug-coated balloons (DCB, 4*120 Passeo-Lux; Biotronik) was elected, concerning the length of the lesion and the immediate proximity to the CFA (Figure 1(d)). Ultrasound, perfusion and clinical examination at 6-months follow-up after the initial procedure revealed a complete recanalization of the SFA and improved claudication symptoms (Rutherford 2, Figures 1(e) and (f) and 2).