Paving and cracking technique for severely calcified SFA lesions
This is a recorded case about the treatment of a severely calcified chronic total occlusion (CTO) of the SFA in a patient with critical limb ischemia. In this video, you will see all the important steps of such an intervention: 1. puncture 2. cross-over sheath advancement 3. crossing of the lesion 4. vessel preparation 5. paving and cracking and 6. final treatment.
Thank you Theo for this interesting case. 2 Questions as always:
1. If you have to deal with such a heavy calcification why not preparing the vessel with endovascular lithotripsy and proceed to either DCB angioplasty or Interwoven stent deployment?
2. Do you think that this patient would benefit from a primary above the knee bypass given
1) the severe calcification and the length of the CTO, which will surely challenge the outcomes of endovascular therapy, and
2) the superior outcomes of primary surgery than secondary grafting after endo failure in CLI patients?
Thanks for sharing this complex case Theo.
Just two comments,
1. How many stents did you finally use in this case? Once you have crossed the lesion why not perform a endobypass with 25 cm Viabahn? or did you use this ballon expandable stent to reinforce the Viabahn??
2. Even with such calcifications, I don’t agree that PTFE fempop bypass has superior patency to endobypass with Viabahn.
3. I know you are most experienced than me, but I recommend you US guided puncture always, specially in this calcified arteries, all closure devices can fail if you puncture in a calcium plaque and the only way to avoid it is with US guidance.
4. Do you see role of SERRATO/CHOCOLATE/SCORED OR CUTTING BALLON for vessel preparation here??
Regarding your questions:
1. Exactly, we performed an endo-bypass with Viabahn and we reinforced the stent-graft at the level of the severe calcification.
2. I have also the same opinion, but this was challenged by other specialists. We have no data regarding this issue in the bypass studies because the quality of the vessel wall was not always analyzed.
3. Totally agree.
4. When you decide to perform an endobypass I do not think that you need such a dedicated device for vessel prep and cause extra costs, because you are going to use a non-compliant balloon for the paving and cracking technique. If you decide to leave nothing or a BMS behind, I would suggest cutting balloon or Shockwave balloon.