Patient History

The patient is a 73-year-old male with a history of diabetes, hyperlipidemia, hypertension, end-stage renal disease, and prior history of tobacco use. After a previous left distal common iliac artery stent placement, the patient presented with life-limiting left lower extremity claudication. Diagnostic angiography revealed an under-expanded left distal common iliac artery stent and a new 90% calcified proximal common iliac artery stenosis.

Treatment Summary

Using ultrasound guidance, access was obtained into bilateral common femoral arteries and 7 Fr 23 cm sheaths were placed. On the left side, a guidewire was advanced and the distal under-expanded stent was treated with a 7 x 20 mm balloon, and subsequently, a 8 x 20 mm balloon at rated burst pressures. The stented segment showed no appreciable luminal gain. The balloon catheter was then removed.

Due to the concern for a similar suboptimal angiographic result for the newer more proximal lesion using the same balloon and stent strategy, the decision was made to modify the calcified plaque using orbital atherectomy prior to stent placement.

The guidewire was exchanged for a ViperWire Advance^® guide wire in the left iliac artery. A peripheral Diamondback^® 2.00 mm Solid Crown was used to perform atherectomy with one pass on medium and four passes on high speed. This was followed by post-dilation with an 8 x 20 mm balloon with full expansion. Kissing balloon angioplasty of bilateral proximal common iliac arteries was performed with two 8 x 20 mm balloons.

A stent catheter was inserted into the left iliac artery and the 10 x 40 mm self-expanding stent deployed across the proximal left common iliac artery lesion. The stent was then post-dilated using a 9 x 40 mm balloon at nominal pressures. A final kissing balloon angioplasty of bilateral proximal common iliac arteries was performed with two 9 x 40 mm balloons.

Bilateral groin hemostasis was obtained with closure devices. The total procedure time from access to hemostasis was 84 minutes.

Angiography revealed excellent stent expansion and apposition with no complications. The patient experienced a complete resolution of claudication symptoms on the left side after the procedure.

Key Takeaways

The use of the Diamondback 360 Orbital Atherectomy device for calcified plaque modification in this patient facilitated stent expansion and led to complete symptom relief.

Previously, in the more distal segment, suboptimal vessel preparation of calcified plaque led to inadequate stent expansion (and accompanying clinical hazards).

The use of the Diamondback illustrated the clinical benefits of the Orbital Atherectomy device to modify calcified plaque as a means of vessel preparation.