Retrograde Treatment in Three Vessels | CSI360

Retrograde Treatment in Three Vessels


Howard J. Feldman, MD FACC FSCAI

Patient History

A 73-year-old male with critical limb ischemia (the most severe form of PAD) and chronic total occlusion (CTO) presented with non-healing ulcers on his right toes and associated osteomyelitis of the right second toe. After a failed antegrade approach, successful retrograde access was achieved through the right anterior tibial artery allowing for treatment of diffuse and densely calcified disease in three vessels.

This Rutherford category 5 patient had multiple risk factors for peripheral artery disease. He was a poorly controlled Type 2 diabetic who continued to use tobacco. Medical history also included hypertension, hyperlipidemia, ischemic heart disease with prior coronary artery bypass grafting (CABG), peripheral neuropathy, and chronic obstructive pulmonary disease (COPD). Previously, he underwent a right common femoral endarterectomy with bilateral femoral popliteal bypasses. A second left femoral popliteal bypass was performed two months after the initial procedure.

Pre-atherectomy assessment showed the right dorsalis pedis pulse to be detectable by Doppler while the right posterior tibial pulse was absent. Angiography revealed CTO of the right femoral popliteal bypass graft, a patent right profunda femoris artery, and a diffuse and densely calcified CTO of the right superficial femoral artery (SFA) extending below the knee into the popliteal artery.*

Treatment Summary

Through retrograde access, a 4 Fr. 60 cm Diamondback 360® Peripheral Orbital Atherectomy System improved distal flow in a Peripheral Artery Disease (PAD) patient with diffuse and densely calcified disease.

Initially, antegrade crossing of the right SFA CTO was attempted but was unsuccessful. Retrograde crossing was then attempted under ultrasound guidance. Retrograde angiography via an anterior tibial access revealed a diffusely diseased anterior tibial (AT) artery and densely calcified subtotal occlusion to CTO of the tibial-peroneal trunk (TPT) and peroneal arteries.

Retrograde anterior tibial access was achieved and a .012″ ViperWire guide wire was advanced across the lesion to the distal right popliteal artery. Orbital atherectomy treatment was completed in three different vessels with a 4 Fr. 60 cm Diamondback 360® 1.25 mm Micro Crown. Since the patient had diffuse disease, multiple lesions were treated within each vessel. The anterior tibial artery was treated followed by the tibial-peroneal trunk and peroneal arteries. Low pressure percutaneous transluminal angioplasty (PTA) was then performed at 6 ATM and 4 ATM in the right peroneal and right anterior tibial arteries, respectively.

Key Takeaways

Orbital atherectomy facilitated reduction in the ostial right anterior tibial artery stenosis from >80% to 0% and reduction in the proximal right peroneal artery stenosis from 95% to <30%. Post-procedural flow was sufficiently enhanced to render retrograde luminal opacification suboptimal. Additionally, the dorsalis pedis Doppler signal changed from monophasic and severely damped prior to treatment to strong and biphasic post-intervention. With improved distal flow to the right foot, the patient was referred for a femoral tibial bypass graft surgery.

  • Successful retrograde access through the right anterior tibial artery was achieved after failing to cross the CTO from an antegrade approach.
  • The unique mechanism of action of orbital atherectomy and the low profile 4 Fr. 60 cm Diamondback 360® 1.25 mm Micro Crown facilitated treatment of three vessel disease.


*WARNING: When treating chronic total occlusion (CTO), create a channel at low or medium speed before traversing the lesion at high speed. Crossing the CTO on high speed may cause the shaft and/or guide wire to fracture as a result of excessive force.

Results may vary.

Pre & Post Procedure Images

SFA CTO prevented an antegrade approach
AT, TPT, and Peroneal Target Lesions. >80% AT and 95% Peroneal Stenosis
60cm Diamondback 360 1.25mm Micro Crown
Post Atherectomy and PTA Results: AT, TPT, and Peroneal vesels treated. 0% AT stenosis, <30% Peroneal stenosis

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