Multimodal Images of Crushed Superficial Femoral Artery Calcified Occlusion Treated by Paclitaxel-Coated Balloon Angioplasty

An 82-year-old man presented with intermittent claudication due to a heavily calcified occlusion in the right mid-superficial femoral artery (SFA), where endovascular therapy (EVT) was performed (Figure A). The intentional penetration of a Jupiter^TM Tapered45 Peripheral Guidewire (Boston Scientific, Marlborough, MA, USA) to the center of the calcified occlusion was confirmed by high-resolution angioscopy (Smart-i; SURGE TECH Corp., Japan; Figure B). After successful crossing using a CROSSER catheter (C.R. Bard, Franklin Lakes, NJ, USA), balloon angioplasty with a 6.0-/120-mm nitinol-constrained chocolate balloon (TriReme Medical, Pleasanton, CA, USA) and 6.0-/200-mm paclitaxel-coated balloon (PCB; Ranger; Boston Scientific) achieved optimal luminal expansion without stent scaffolds (“crushed calcification” strategy). Intravascular ultrasound (IVUS; AltaView^TM; Terumo, Tokyo, Japan) and optical frequency domain imaging (OFDI; FastView^TM; Terumo, Tokyo, Japan) after PCB angioplasty demonstrated the optimal luminal condition (Figure B–F). OFDI visualized the calcified lumen in the SFA lesion more clearly than IVUS.¹ Although IVUS had difficulty detecting PCB drug particle adhesion to the vascular wall due to severe calcification, OFDI confirmed it with direct visualization on angioscopy (Figure B). Thereafter, no claudication occurred for 6 months.

Figure.

(A) Initial digital subtraction angiography (DSA). (B) Comparison of multimodal images. Arrowheads indicate circumferential calcification. Circles and arrows indicate drug adhesion. (C–E) Angiography showing the crossing procedure (C), after crossing (D), and optimal balloon expansion (E). (F) Final DSA.

EVT of calcified occlusions is challenging; however, the “crushed calcification” strategy with balloon angioplasty through the center of calcified lesions can be effective in achieving luminal expansion without stent implantations. In the present case, the luminal characteristics of post-crushed calcification and optimal PCB drug adhesion were first demonstrated on multimodal images. Furthermore, OFDI-guided EVT with PCB angioplasty may be useful for calcified lesions because OFDI can predict restenotic risk factors after balloon angioplasty.¹

Reference

• 1.   Tsukiyama Y, Konishi A, Shinke T, Kozuki A, Otake H, Kawamori H, et al. Open-label multicenter registry on the outcomes of peripheral arterial disease treated by balloon angioplasty with optical frequency domain imaging in superficial femoral artery and popliteal artery (OCEAN-SFA study). Cardiovasc Interv Ther 2021; 36: 321–329.