Direct Puncture of Calcified Plaque Using a Percutaneous Transcholangiography Needle in Endovascular Treatment for Superficial Femoral Artery Chronic Total Occlusion: A Case Report

Endovascular treatment (EVT) for chronic total occlusion (CTO) lesions has progressed recently; however, severely calcified lesions remain difficult to treat owing to challenges in guidewire passage and limited balloon or stent expansion. We report the case of a 79-year-old Asian male with intermittent claudication who had previously undergone bare metal stent (BMS) implantation for CTO of the left superficial femoral artery (SFA). He underwent open surgical repair with end-to-end anastomosis of the left common femoral arter (CFA) to treat a puncture-site perforation. However, a chronic left CFA aneurysm later developed despite the initial repair. Angiography revealed a completely occluded SFA with a severely calcified plaque distal to the BMS. We selected a retrograde approach to perform EVT for the CTO of the left SFA via the popliteal artery, to avoid the ipsilateral antegrade approach crossing the aneurysm. As the puncture site was near the lesion, a direct puncture of the plaque was performed from the inserted sheath using a percutaneous transcholangiography (PTC) needle (calc-pick technique). The implanted BMS and calcification were useful as markers for needle insertion. To confirm the direction, we advanced the needle into the calcified occlusion and introduced a 0.014-in. wire toward the distal true lumen. After the wire position was confirmed using intravascular ultrasonography, step-by-step balloon dilatation was performed. A drug-coated balloon was used to finalize the procedure, resulting in good forward flow without any complications. Therefore, direct puncture of a severely calcified plaque with a PTC needle is a useful and safe EVT strategy if the lesion is close to the puncture site.