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

Avignon, France

Interventional cardiologist

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