62-year-old patient, he has end-stage renal disease and multiple other comorbidities. He's on hemodialysis, and he is my coronary patient. He had stable PAD, no symptoms, had an LCA stent, was doing fairly well. One day after a fairly long no-show period, shows up to clinic, and he's hobbling along saying, I have right leg pain for two weeks. He saw his primary care, who gave him Lyrica and gabapentin, it didn't get better. On examining, he does not have pedal signals, cap refill was about five seconds, but still walking on the leg. So gabapentin will not fix this, that was very clear. We sent him for ABI, on the right the ABI was zero, on the left it was 1.3, likely due to non-compressibility in the setting of end-stage renal disease. Low pressures on the right was zero, and critically low on the left at 0.14. So we got him admitted and brought him for an angiogram. So this was the initial angiogram, you had to take my word to say that there was moderate calcific disease, but nothing high-grade in the aorta iliac segments. Then we crossed and did a run-off of the leg. He could not stay still for me at all. He had some calcific nodular SFA disease, nothing high-grade at this stage, but really, really could not keep him still in spite of escalating doses of sedation. By the time we get to the knee area, he's trying to like sit up and kick me. So then I just did a coronary CNA run, which we could see that it comes up to the pop and stumps off, very much in sync with his symptoms of two weeks. So, you know, I told my staff, this is going to be quick, let's quick get a catheter down here and get him off the table. We get a guiding catheter down, and it took about 30 seconds to realize that this was not thrombus, but very heavily calcified popliteal occlusion. I poked it with a couple of wires while he was moving, but there was like no chance of crossing here. So we stopped and brought him back the next day. And this is his angiogram. So we see that he's occluded at the popliteal, reconstitutes at the peroneal and AT, and there might be a little shadowing with calcific disease in the distal popliteal and TP trunk. So the next day when I brought him, we brought him back with anesthesia, as we discussed this morning at a session, if anesthesia is something that's used commonly. I use anesthesia in situations like this. If I cannot get control of the situation with moderate sedation, and I am like bordering intubation here, I just stop if I can and bring the patient back with anesthesia. We got anti-grade access on the right. That way we have a higher success rate, had the foot prepped, gave a lot of nitro and got that previous picture. Just like Peter explained why escalation with the support catheter was undertaken, and changing the fluoro angle because I could see where the calcium was, I very slowly traveled that calcific popliteal. Just following the architecture every time it tries to move out of the architecture, just redirecting. We were finally able to escalate and escalate and escalate and cross with the O1-8 ASTATO-30. And I was really getting desperate here. We had been exchanging multiple wires with the CXI backup catheter because just the distal cap could not be traversed. We went from the O1-4 FIELDER-XT through pilot wires, through CONFIANZA, through O1-4 ASTATOS to the O1-8 ASTATO, and that is what we crossed with. So this is the roadmap picture, and you see when the situation is under better control, this looks much better than what we had the previous day. So I crossed here, and now we were all quite excited because this took a good two hours to get through. And advanced the microcatheter just enough, changed the wire, and performed atherectomy. So this is what we get with atherectomy. What would the panel do at this point? Yeah, you still have runoff, right? I have a peroneal runoff, and that's unchanged from before. Any thoughts, quickly? Zola, or Chris, what are you going to do? I don't know. Is there a catheter in that? That's a half of the line right down the middle of that thing. That's a catheter, yeah. It's either a quad or a catheter. No, it's the CXI down there. Okay. That was in the midst of exchanging the wire. What was the name of the CSI? CSI, yeah. This is the CXI exchange catheter. Okay. So orbital. All right. So... So we balloon dilate this thing. That's what it looks like, right? Right. So we balloon dilated and IVest, right? Okay. And after the balloon dilatation, the dissection really didn't change. So at this point, it's 10, right? With the IVest, 4-5 supera in the P3, 5-5 supera in P2. And this was the final angiogram. So we got away here. But my point here was in spite of IVesting afterwards, I don't want to use the word cavalier, but I wasn't cautious enough that from the atherectomy, I should not have used like a one-to-one balloon and balloon this thing that had so much calcium. Instead, we should have slowly dilated up, used intravascular IVL, and tried to really gain a nice lumen before we inflated a one-to-one balloon. So at the end of this case, the patient had a monophasic loud PT. TBIs were 0.4, still low, but not critical. And he's been asymptomatic for nine months. I'm just waiting for him to show up with the other side because those of us who do this know that if one side goes down, the other side does too. But a couple points with this case was if we had failed antigrade crossing with escalation, what options do we have here? So one is we could consider if there was an option for bypass. And really, there was not good enough a target. We could try again, or we do it under better control conditions. Certainly consider alternate access. And in this patient, he had single vessel runoff with the peroneal. And would the panel be comfortable sticking the peroneal, last remaining vessel? Yes, definitely. Because if not, he's going to lose his leg. So definitely, we have to be comfortable enough to get to that point to be able to access the last remaining TBL. Another thing I have done when I just can't cross is bring a laser down to the proximal cap and sit it there for a little while. And that gives us enough modification of the plant to get a heavy wire through. And finally, you can always refer to a friend, right? Okay. So calcium reconsideration, IVUS for guidance. And when you see the IVUS, act on it. You know, this was the IVUS at the P2 segment. This is not going to expand with the balloon, you know, even after IVL and balloon angioplasty. So cutting balloons, atherectomy, and all of those have to be used in conjunction to really prepare the vessel. And then you can finally decide if it's chint or balloon only. Thank you. Thank you.

end-stage renal disease

multiple comorbidities

right leg pain

popliteal artery occlusion

atherectomy

calcium

laser

orbital

plaque