Retrograde Treatment 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.*

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.