Retrograde Treatment SFA CTO


Mahir D. Elder, MD

Patient History

A 58-year-old African American male presented with a CTO of the SFA and a non-healing ulcer of the great toe. Multiple attempts to cross the lesion from an antegrade approach were unsuccessful despite the use of a variety of catheters, wires, and other devices. Finally, retrograde access through a collateral artery was achieved and the Diamondback 360® 1.25 mm Micro Peripheral Orbital Atherectomy System was used to successfully treat the calcified lesion.

This patient presented with complaints of severe claudication. He was unable to walk more than 50 feet significantly limiting his ability to perform activities of daily living.

The patient was also forced to resign from his job as a tow truck driver due to severe lower extremity pain.

The patient’s major contributing risk factor for peripheral artery disease (PAD) was diabetes. He was Rutherford category 4 to 5. The patient had not received prior surgical treatment for PAD.

Angiographic assessment prior to atherectomy showed a right SFA CTO greater than 250 mm in length, which was heavily calcified and visible under fluoroscopy.

Treatment Summary

After multiple failed antegrade crossing attempts, retrograde crossing of the superficial femoral artery (SFA) chronic total occlusion (CTO) via the medial collateral artery was achieved; the lesion was successfully treated with a 145 cm Diamondback 360® 1.25 mm Micro Crown without the need for post-atherectomy stent placement.*

Flush ostial CTO prevented an antegrade approach despite several attempts and the use of multiple devices. Retrograde crossing via the medial collateral artery was attempted and achieved. A right SFA stick was performed and a 5 Fr introducer sheath was placed. The medial collateral artery was successfully crossed and the SFA was re-entered below the lesion. The CTO was then crossed via a retrograde approach and successful atherectomy of the heavily calcified lesion was achieved with a 145 cm Diamondback 360® 1.25 mm Micro Crown. The crown was passed two times on low speed.

After atherectomy, balloon dilatation was performed using a 4.0 mm X 120 mm Chocolate® Balloon [TriReme Medical] at 8 ATM for 2 minutes and a 3.5 mm balloon catheter at 6 ATM for 3 minutes. No waist was observed in either balloon.

Key Takeaways

After atherectomy and adjunctive PTA, residual stenosis in the SFA was 10%. Stent placement was not required. The patient later stated that his leg and foot pain had subsided substantially and the ulcer on his great toe had begun to heal. The patient was optimistic about returning to work.

  • The low profile design of the 145 cm 1.25 mm Diamondback® Orbital Atherectomy Micro Crown allowed retrograde traversing of a collateral artery.
  • Patient successfully treated via retrograde access after multiple failed attempts to treat antegrade.


*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

Pre-Atherectomy Right SFA. 100% occluded (CTO) stenosis.
1.25mm Micro Crown in the Right SFA.
Chocolate PTA Balloon Catheter in the Right SFA.
Post-Atherectomy and PTA Right SFA. 10% residual stenosis.
Pre-Atherectomy Below-the-knee.
Post-Atherectomy and PTA Below-the-knee.

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