A 45-year-old male, 5′9″ height, with hypertension, hyperlipidemia, type 1 diabetes mellitus, and severe peripheral arterial disease, requiring right fourth and fifth metatarsal amputation for osteomyelitis, noted to have poor wound healing. RLE arterial duplex notable for 50 to 99% stenosis of tibioperoneal (TP) trunk and anterior tibial artery. Left radial artery access is obtained and a 0.035″ wire and 4-Fr glide catheter are used to navigate to the proximal SFA. The catheter is exchanged for a 6-Fr 119-cm Destination Slender sheath (Terumo; not shown) which is parked in the proximal SFA. A 400-cm Viper wire is advanced through the TP trunk into the posterior tibial (PT) artery and the (a) Diamondback orbital atherectomy device (Cardiovascular systems) is positioned over the wire just proximal to the TP stenosis. (b) Atherectomy is performed of the TP trunk lesion followed by (c) balloon angioplasty using a 4-mm 180-cm-long shaft Ultraverse Rx (Bard) balloon. (d) Postangioplasty runoff shows severe focal stenosis of the lateral plantar artery. The Viper wire is advanced distal to the stenosis and 3 mm 180-cm-long shaft Ultraverse Rx (Bard) balloon is used to angioplasty the stenosed segment. (f) Postangioplasty angiogram shows markedly improved flow through the lateral plantar artery. Patient evaluated in clinic 1 month after procedure and noted to have completely healed right foot wounds.

A 63-year-old male, 5′10″ height, with treated hepatitis C, HIV, prior deep vein thrombosis/pulmonary embolism on therapeutic anticoagulation, prior EVAR for symptomatic aortic thrombus, now presenting with progressive RLE claudication symptoms developing while walking greater than 1/2 block. (a) CT angio MIP showing diffuse right SFA atherosclerotic disease with an approximately 11 cm segment of severe stenosis from mid to distal SFA. Left radial artery access is obtained and a 0.035″ wire and 125 cm 5 Fr guide catheter (Cordis) are used to navigate to the proximal SFA. The guide catheter was left in place as it was felt that the patient's radial artery was not adequately sized for a support sheath. The 0.035″ wire is exchanged for a 480-cm 0.018″ guidewire (Boston Scientific) which is advanced distal to the lesion into the popliteal artery. (b) Digital subtraction angiogram confirms CT Angio findings of the mid-distal SFA stenotic segment. (c) Angioplasty of the stenosed segment is performed using a 4-mm 180-cm-long shaft Ultraverse Rx (Bard) balloon and a (d) postangioplasty angiogram shows significant residual stenosis. (e) A 6 mm × 15 cm Everflex self-expanding stent (Medtronic) is deployed across the stenotic segment and postdilated with a 4-mm balloon. (f) Completion angiogram shows markedly improved flow through the SFA. Patient evaluated in clinic 1 month after procedure and noted to have significantly decreased claudication symptoms.