Manipulation of a Bent Bare Metal Needle for Breaking Calcified Obstruction via a High‐Precision Orifice Puncture Into the Keystone Deep Femoral Artery (Bamboo Hook Technique)

Severely calcified ostial occlusion of the deep femoral artery (DFA) is a condition that is technically challenging to manage. Surgical reconstruction has been traditionally considered the most reliable treatment option, and evidence on feasible endovascular strategies remains limited. Herein, we report the case of a woman in her 80 s who presented with Rutherford class 5 lower-extremity arterial disease and a nonhealing ulcer of the right first toe. A long-segment occlusion of the superficial femoral artery (SFA) with heavy calcification and an ostial occlusion of the DFA were observed on angiography. The SFA was successfully revascularized with stent placement. However, revascularization of the DFA origin was required to secure a collateral source because of the risk of acute limb ischemia due to multiple implanted stent grafts. The antegrade and retrograde wiring attempts were not successful owing to severe calcification and jailed stent struts. Therefore, a modified stylet puncture-based direct orifice puncture of the DFA origin was performed via manipulation of a Bent bAre Metal needle for Breaking calcified ObstructiOn using a High-precisiOn Orifice puncture into the Keystone DFA (referred to as the "BAMBOO HOOK") technique. A pull-through was established, and balloon angioplasty yielded sufficient lumen gain despite the jailed stent struts. Hemostasis was secured via prolonged balloon inflation, and complete wound healing was achieved approximately 3 months after minor toe amputation. The bamboo hook technique can be a feasible endovascular approach for recanalizing severely calcified ostial occlusions of the DFA.