Atherectomy as a Crucial Technique for Achieving Peripheral Vascular Intervention in Complete Vessel Occlusion With Severe Calcification

Andrew Ibrahim, Caroline Cushman, Mitchell DeVolder, Hoang Ho, Annmarie Farag, Dixon Santana, MD, Mohammad (Mac) Ansari, MD

PAD Center of Excellence, Texas Tech University Health Sciences Center, Lubbock, Texas

Introduction

Severe vascular calcification remains a persistent challenge to peripheral vascular intervention (PVI). Historically, balloon angioplasty has been used in the management of calcified lesions, yet this method has shown limited effectiveness in heavy calcification. Orbital atherectomy (OA) is a novel technique that has demonstrated superior debulking of heavily calcified vessels with efficacy and safety. The use of OA has optimized outcomes of PVI in complex, calcified lesions, yet its use has recently been heavily debated. We present a patient in which atherectomy, particularly orbital atherectomy, was the last resort in achieving multivessel PVI in an otherwise high-risk non-surgical candidate.

Case Presentation

Male age 82 with PMH of HTN, DM, CAD, and PAD presented with exertional dyspnea and severe claudication. Angiography revealed multivessel stenosis with chronic total occlusion (CTO) of the superficial femoral artery (SFA) and popliteal artery (PA).

Retrograde right femoral access was used and multiple subsequent techniques were applied to cross the completely occluded lesion. Due to severe calcification, there was extreme difficulty advancing any equipment, and after multiple attempts, the decision was made to proceed with atherectomy. Orbital atherectomy of the SFA and PA was successfully performed using the CSI Diamondback system, achieving the luminal gain needed to deliver initial balloon angioplasty, followed by stent placement, and hence, percutaneous endoluminal bypass was performed due to vessels obliterated by severe calcification, resulting in restored perfusion to the lower extremity.

Discussion

In this high-risk non-surgical candidate, PVI was the last available revascularization option. Due to severe calcification, however, PVI was made possible only through the debulking provided by atherectomy. This case is a glaring example of the necessity of atherectomy, specifically orbital atherectomy, in achieving successful intervention in severe vessel calcification. This technique poses as a valuable tool in deliverability to perform percutaneous endoluminal bypass when no alternative options are available.