The patient had a history of peripheral artery disease (PAD), neuropathy, diabetes, coronary artery disease, hypertension, and hyperlipidemia. He has smoked 3 to 4 packs per day for the past 47 years. Rutherford classification was category 4 due to rest pain.

Prior treatments for PAD (including a non-healing right leg ulcer of 2 to 3 months duration) included above the knee balloon angioplasty and stent placement in the left superficial femoral artery (SFA) in August 2013 and the left and right common iliac arteries in July 2013. The right leg ulcer healed completely but the patient continued to complain of claudication mainly in the left leg. Walking was limited to less than 100 yards.

Assessment prior to atherectomy showed a severely calcified lesion in the TPT, which was 80 mm long and 80% stenosed. Severe disease was also noted in the popliteal artery and the superficial femoral artery (SFA) with in-stent restenosis (ISR).

Prior to treating below-the-knee lesions with orbital atherectomy, the patient underwent endovascular treatment for inflow disease. After accessing the anterior tibial artery via ultrasound guidance and treating inflow disease through a 6 Fr sheath, a guidewire was used to cross the TPT lesion and advanced down into the posterior tibial artery from the sheath placed in the distal anterior tibial artery. After exchange of the Asahi Regalia for a 0.012″ CSI ViperWire®, orbital atherectomy was carried out using a 60 cm Diamondback 360® Peripheral Device 1.25 mm Solid Crown. The initial pass of the crown was at low speed for 30 seconds. This was followed by two additional passes, one at medium speed for 15 seconds and a final pass at high speed for 20 seconds.

After orbital atherectomy of the TPT, balloon dilatation was performed using a 4.0 mm x 80 mm Chocolate® Balloon [TriReme Medical] at 6 ATM for 3 minutes. No waist was observed in the balloon.

Total procedure time for the retrograde anterior tibial artery approach and treatment of the TPT was approximately 11 minutes, which included passing and exchange of the guide wires, access of the TPT lesion, atherectomy, and post-atherectomy balloon angioplasty.