Long-term outcomes of the “pave-and-crack” technique for severely calcified femoropopliteal chronic total occlusions

Abstract Objective To evaluate the long-term safety and efficacy of the pave-and-crack technique, combining aggressive balloon dilatation and covered stent implantation, for endovascular therapy (EVT) of highly calcified femoropopliteal chronic total occlusions (CTOs) in poor surgical candidates unsuitable for open revascularization or conventional EVT. Design Single-center retrospective cohort study based on a prospectively maintained peripheral artery disease database. Methods Patients with symptomatic femoropopliteal CTOs treated using the pave-and-crack technique between September 2014 and April 2025 were included. Lesion and procedural characteristics, technical success, defined as residual stenosis ≤ 30%, complications, major target limb amputation, and symptom status were assessed. Kaplan–Meier analysis was used to estimate freedom from target lesion revascularization (TLR) and all-cause mortality through 5 years. Results A total of 122 patients with 136 femoropopliteal CTOs were treated. Mean lesion length was 253.0 ± 90.1 mm, and 93.4% (127/136) of lesions were severely calcified. Retrograde access was required in 72.8% (99/136) of procedures. Technical success was achieved in 93.4% (127/136). Freedom from target lesion revascularization was 91.4% ± 2.6% at 1 year, 77.9% ± 4.6% at 3 years, and 66.7% ± 7.2% at 5 years. Major target limb amputation occurred in four cases presenting with CLTI (8.5%; 4/47) and none with claudication (0%; 0/89). Five-year freedom from all-cause mortality was 71.4 ± 6.9% for claudicants and 41.4 ± 11.2% for patients with CLTI ( p < 0.01). Conclusion The pave-and-crack technique is feasible for highly calcified femoropopliteal CTOs, achieving high technical success, encouraging long-term freedom from TLR, and high limb salvage. Graphical Abstract Long-Term Outcomes of the “Pave-and-Crack” Technique for Severely Calcified Femoropopliteal Chronic Total Occlusions. (Left) Lesion and Procedural Characteristics. (Middle) the “Pave-and-Crack” Technique (A) Fluoroscopy showing aggressive balloon pre-dilatation. (B) Angiography showing vessel rupture. (C) Fluoroscopy following covered stent implantation (Viabahn) and relining with an interwoven nitinol stent (Supera). (D) Final angiography. (Right) Kaplan Meier survival curves and estimates for freedom from target lesion revascularization over five years stratified for popliteal involvement (segment P1-P3). CLTI: Chronic limb threatening ischemia. CTO: Chronic total occlusion. PACSS: Peripheral Calcification Scoring System. PTA: Percutaneous transluminal angioplasty. KM: Kaplan-Meier, SD: Standard deviation, TLR: Target lesion revascularization.