Peripheral
SFA

IVL in PAD: crossing calcified lesions

A 69-year-old male with a complex vascular history, including prior stents and endarterectomy, presents with worsening left leg ischemia (Rutherford class IV). Investigations demonstrate significant atherosclerotic disease in the left SFA, including occlusions and calcifications. What are your therapeutic recommendations for this challenging case?

Jérôme Brunet
Jérôme Brunet
Avignon, France
Interventional cardiologist
Gilles Goyault
Gilles Goyault
Strasbourg, France
Interventional radiologist
Part I - Case presentation

A 69-year-old patient presented with :

  • Coronary diseases / obesity / diabetes / dyslipidemia / hypertension/ ischemic stroke
  • Previous bilateral common iliac artery (CIA), left external iliac artery (LEIA) and feft SFA stenting, together with thromboendarterectomy of both common femoral arteries (CFA)
  • Worsening clinical status with Rutherford IV on the left side 
  • Recent investigations showing:
    • Angio-CT scan: suspicion of calcified lesion on left femoral bifurcation and superficial femoral artery (SFA)
    • Per-operative angiography: aorto-ilio-femoral patency associated with important SFA lesions and thrombosis on SFA-popliteal artery on the left side

Crossover 5Fr UF catheter

Per-operative angiogram for the femoral bifurcation:

  • CFA patent
  • No stenosis noticed

Per-operative angiogram for the left leg with oblique view:

  • Significant stenosis noticed

Per-operative angiogram for the left leg:

  • Occlusion 1/3 mid – 1/3 inferior of SFA
  • Important calcifications
  • Very slow flow
  • Popliteal artery patent
  • Calcified lesion noticed
  • BTK arteries with lesions but continuous flow

Powered by Quiz Maker

 

Part II - Our treatment
  • Crossover from right to left to cross SFA and popliteal lesion: IVL and DEB strategy
  • Antegrade puncture if required
  • Provisionnal stenting if necessary
  • Outpatient treatment
     
  • 5 Fr sheath access by crossover
  • Difficulties due to femoral fibrosis + previous iliac stenting
  • Crossover achieved with swallow technique using Cordis Saber 6 x 20 mm balloon
  • 5 Fr catheter 90 cm advanced on Terumo Advantage® 0.035 guidewire
  • Close angiography showing complete calcified occlusion on distal SFA
  • From crossover to antegrade treatment
  • 5 Fr catheter + crossing catheter Sergeant 0.018 130 cm + ASAHI Gladius® MGPV ES 0.018 300 cm
  • No torque + friction +++
  • Crossing impossible
  • New crossing attempt with ASAHI Halberd® 0.014 300 cm
  • Crossing failure
  • Decision to perform an antegrade puncture on the direct proximal SFA
  • Antegrade crossing with 6 Fr sheath 45 cm close to lesion + ASAHI Astato® 30 0.018 + microcatheter 0.018
  • Crossing initiated and distal lesion pre-occluded : decision to change the guidewire strategy with navigation-dedicated guidewire
  • New attempt with ASAHI Gladius® XT 0.018
  • Successful completion of the crossing
  • Angioplasty ABBOTT Armada™ 0.018 4 x 60 mm vessel preparation
  • IVL Shockwave MS 6 x 60 mm
  • Multi-level staged IVL on calcified lesion
  • Progressive opening lesion with IVL treatment
  • Angiogram control with efficient result on calcified lesions after IVL therapy
  • Debulking technique
  • 3.0 mm (with fins) crossing
  • multi-crossing if required
  • Medication: IV 3 mg Risordan + 2 mg Ispotine
  • Complementary DEB therapy
  • Ivascular Luminor 18 6 x 150 mm
  • 3-minute inflation 
  • Angiogram control
  • Good result post-DEB
  • Calcified stenosis remaining above treated lesion
  • Decision for provisional stenting
  • Provisional stenting with ABBOTT Supera™ 5.5 x 200 mm
  • Very slow and adequate deployment
  • Angiogram control
  • Excellent result
  • Excellent flow
  • Proximal control
  • Excellent result 
  • Excellent flow
  • Excellent control and run-off
  • End of procedure 
  • Double closure with closure device Femoseal©
  • Outpatient procedure