case_images: PMC6500656_01
case_images: The first angiogram. (a) Digital angiography shows severe calcification of the right superficial femoral artery. (b) Digital subtraction angiography of the proximal part indicates the chronic total occlusion of the middle superficial femoral artery. (c) Digital subtraction angiography of the distal portion presents the puncturable distal superficial femoral artery.
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case_images: fig1
case_images: The first angiogram revealed the severely calcified SFA-CTO (Figure 1; Video Clip S1).
case_images: Rendezvous technique. The retrograde wire progresses into the antegrade child catheter.
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case_images: fig2
case_images: Finally, the retrograde-antegrade rendezvous technique led to wire externalization (Figure 2; Video Clip S2).
case_images: Devices that failed to cross the lesion. (a) The thin balloon is bent. (b) The Corsair PV microcatheter is fractured. (c) Crosser system cannot pass the lesion. (d) The needle cracking technique from outside of the vessel. (e) Needle cracking technique from inside of the vessel using the stiff wire. (f) Needle cracking technique from inside of the vessel using the tail of the wire. (g) The thin balloon cannot pass the lesion even after these devices and techniques.
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case_images: fig3
case_images: Despite using all these techniques, a minimal balloon could not pass the lesion (Figure 3).
case_images: Combined strategy of the excimer laser atherectomy and high-speed rotational atherectomy. (a) The excimer laser catheter (Turbo Elite 0.9 mm) also cannot cross the lesion; however, it modifies the morphology of the chronic total occlusion lesion. (b) The Caravel microcatheter can pass the lesion. (c) Exchanging to the 0.009-inch Rota-wire from the conventional 0.014-inch wire, 1.5 mm burr ablation is performed.
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case_images: fig4
case_images: Turbo Elite 0.9 mm (Spectranetics, Co., USA). This device also could not pass the lesion; however, it modified the CTO entry-morphology (Figure 4(a)). After ELA ablation, the Caravel microcatheter (ASAHI Intecc) finally crossed the lesion using an antegrade approach with the BAlloon Deployment using FORcible Manner (BADFORM) technique (Figure 4(b)), which enabled change of the wire from conventional the 0.014-inch wire to 0.009-inch RotaWire floppy (Boston Scientific) and RotaLink Plus 1.5mm burr ablation (Boston Scientific) (Figure 4(c)).
case_images: The final angiogram. (a) Digital subtraction angiography of the proximal superficial femoral artery. (b) Digital subtraction angiography of the distal superficial femoral artery.
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case_images: fig5
case_images: The final angiography revealed acceptable result without delay in blood-flow or bleeding complications (Figure 5; Video Clips S3 and S4).