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Nothing Left behind Strategy: Long SFA lesion, Directional atherectomy & DCB

Case of the Month: December 2018

This didactic procedure concerns a 62 years old man, presenting severe right limb intermittent claudication (Rutherford 3) &  long proximal SFA lesion with subsequent short occlusion.

It was treated by contralateral and retrograde approach, the lesion was prepared with directional atherectomy & a new cutting balloon (Chocolate-Medtronic). A good final result was obtained with  DCB angioplasty. 


Educational objectives

  • How to deal with extensive SFA disease.
  • How to performSFA  retrograde puncture, crossing and guidewire externalization. 
  • Effectivness of Directional atherectomy in long SFA lesions.
  • Optimal vessel preparation with combined atherectomy & cutting balloon.
  • How to leave Nothing behind.

Step-by-Step description

  • Left femoral access 7F (Contralateral approach).
  • Crossover approach with 6F long sheath assisted by Admiral 6x40mm balloon.
  • Approach lesion with 0.018" Command guidewire supported by Trailblazer microcatheter.
  • After Command & Connect guidewires failure, a retrograde approach is decided.
  • Retrograde puncture of the distal right SFA.
  • Retrograde crossing of the lesion & externalization of the command over a BER catheter.
  • Filter placment in the distal popliteal artery.
  • predilatation with 3.5mm balloon of the occluded zone.
  • Directional atherectomy using a HawkOne device 7F.
  • Balloon dilatation with a 5x80mm balloon : distal & proximal SFA.
  • Second directional atherectomy run.
  • Distal SFA dilatation with Chocolate 6x40mm balloon (Medtronic).
  • Multilevel dilatation with DCB : IN PACT Pacific 5x120mm (Medtronic)
  • Distal filter retreiving Spider 7mm (Medtronic).
  • Final angiographic control.


  • Procedure time: 90 min
  • Exposure time: 29 min
  • Exposure: 321 mGy
  • Contrast volume: 120 ml


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