Anterior tibial artery revascularization with piercing technique.

This case report was previously published in CLIC LATAM course in 2019.

We report case of a 60-year-old male patient with a history of hypertension and diabetes mellitus who currently has critical limb ischemia of the left foot with rest pain and trophic disorders at second and third toes and the forefoot. (WIfI 122 classification).

Angiography showed occlusion of both tibial arteries.

Due to the high risk of amputation, it was decided to continue with angioplasty of both tibial arteries.


Ultra-sound guided puncture of the left common femoral artery.

5 Fr sheath placement.

CXI support catheter.

V-14 and V-18 guidewires.

Conventional balloon angioplasty.

Endoluminal and antegrade revascularization with balloon angioplasty of the posterior tibial artery was performed without complications.

The anterior tibial artery could not be recanalized anterogradely with the V-14 guide, so a V-18 guide was used. Once the V-18 guidewire was located in the dorsalis pedis artery, an unsuccessful attempt was made to progress the CXI catheter to be able to exchange the 0.018” guide for a 300 cm 0.014” guide and perform balloon angioplasty due to the severe calcification of the vessel. A piercing technique was performed by fracturing arterial calcium with the percutaneous puncture of the vessel with an 18G puncture needle at the ankle level. Then, the progression of the  CXI catheter towards the dorsalis pedis artery is achieved and the exchange of guides is carried out to continue with balloon angioplasty. There were no complications secondary to the use of an aggressive technique such as “piercing” in this case, which carries a high risk of amputation without adequate revascularization.


    Naren Gupta
    May 14, 2020

    Dr Voos, That was a nice presentation and a great result. Can you tell us what was the sequence of balloon sizes that you used? Do you do any other, more typical vessel prep for highly calcified lesions in BTK interventions?

    Dear Dr. Naren Gupta
    Thanks for your comments.
    I used in this case a coronary non-compliant balloon for vessell preparation in the mostly calcified zone after the piercing technique. Then I used Coyote balloons for dilatation (2.5 mm and 3.0 mm).
    In my daily practice, I use non-compliant balloons and rotational atherectomy for vessel prep for highly calcified lesions in BTK interventions.

Leave a Reply