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This didactic procedure concerns a 62 years old man, presenting severe right limb intermittent claudication (Rutherford 3) &  long proximal SFA lesion with subsequent short occlusion.

It was treated by contralateral and retrograde approach, the lesion was prepared with directional atherectomy & a new cutting balloon (Chocolate-Medtronic). A good final result was obtained with  DCB angioplasty. 

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Educational objectives

• How to deal with extensive SFA disease.
• How to performSFA  retrograde puncture, crossing and guidewire externalization. 
• Effectivness of Directional atherectomy in long SFA lesions.
• Optimal vessel preparation with combined atherectomy & cutting balloon.
• How to leave Nothing behind.

Step-by-Step description

• Left femoral access 7F (Contralateral approach).
• Crossover approach with 6F long sheath assisted by Admiral 6x40mm balloon.
• Approach lesion with 0.018" Command guidewire supported by Trailblazer microcatheter.
• After Command & Connect guidewires failure, a retrograde approach is decided.
• Retrograde puncture of the distal right SFA.
• Retrograde crossing of the lesion & externalization of the command over a BER catheter.
• Filter placment in the distal popliteal artery.
• predilatation with 3.5mm balloon of the occluded zone.
• Directional atherectomy using a HawkOne device 7F.
• Balloon dilatation with a 5x80mm balloon : distal & proximal SFA.
• Second directional atherectomy run.
• Distal SFA dilatation with Chocolate 6x40mm balloon (Medtronic).
• Multilevel dilatation with DCB : IN PACT Pacific 5x120mm (Medtronic)
• Distal filter retreiving Spider 7mm (Medtronic).
• Final angiographic control.

Protocol

• Procedure time: 90 min
• Exposure time: 29 min
• Exposure: 321 mGy
• Contrast volume: 120 ml
   

Biobliography

• 2017 ESC Guidelines on the Diagnosis and
  Treatment of Peripheral Arterial Diseases,
  in collaboration with the European Society

  for Vascular Surgery (ESVS) - Article
  
   
• Combined HawkOne directional atherectomy and paclitaxel-coated balloon angioplasty for isolated calcified popliteal artery lesion: a no-stent approach to lower extremity endovascular revascularization. - Article
  Authors: Loffroy R, Chevallier O, Falvo N, Gehin S, Midulla M, Galland C.
  Publication:doi: 10.21037/qims.2018.03.10.
   
• Directional Atherectomy Followed by a Paclitaxel-Coated Balloon to Inhibit Restenosis and Maintain Vessel Patency: Twelve-Month Results of the DEFINITIVE AR Study. - Article
  Authors: Zeller T, Langhoff R, Rocha-Singh KJ
  Publication doi:10.1161/CIRCINTERVENTIONS.116.004848.
   
• Debulking Atherectomy in the Peripheral Arteries: Is There a Role and What is the Evidence? - Artice
  Authors: Katsanos K, Spiliopoulos S, Reppas L, Karnabatidis D.
  Publication doi: 10.1007/s00270-017-1649-6. Epub 2017 Apr 27.
   
• Combined treatment of heavy calcified femoro-popliteal lesions using directional atherectomy and a paclitaxel coated balloon: One-year single centre clinical results. - Article
  Authors: Cioppa A, Stabile E, Popusoi G, Salemme L, Cota L
  Publication doi: 10.1016/j.carrev.2012.04.007. Epub 2012 May 25.
   
• A prospective, multi-center study of the chocolate balloon in femoropopliteal peripheral artery disease: The Chocolate BAR registry. - Article
  Authors: Mustapha JA, Lansky A, Shishehbor M, Miles McClure J, Johnson S, Davis T, Makam P, Crowder W, Konstantino E, Attaran RR; Chocolate Bar Investigators.
  Publication doi: 10.1002/ccd.27565. Epub 2018 Mar 7.