Abstract
BackgroundThe patency achieved by conventional peripheral interventions for atherosclerotic lesions in the common femoral artery (CFA), called the “no stenting zone”, is not superior to that achieved by surgical endarterectomy due to calcified plaque occupying the area. Plaque modification strategies to obtain acute gain in CFA patency provide the better clinical outcomes than standard balloon angioplasty. Atherectomy devices, which focus on the modification of superficial calcifications, contribute to the improvement of clinical outcomes. However, deep calcifications resist vessel expansion such that luminal gain is not easily achieved.Main textWe propose a novel calcified plaque modification technique, named the “fracking technique” (FT). The term fracking refers to how a rock is fractured by the high hydraulic pressure. In this technique, deep calcifications are cracked with hydraulic pressure via a balloon indeflator through an 18-gauge needle, which punctures calcifications to achieve greater acute luminal gain. Case 1 involved an 81-year-old male with eccentric calcified plaque in the right CFA. Conventional balloon angioplasty for the lesion yielded a suboptimal minimal lumen area (MLA), which increased from 6.2 to 10.7-mm2 on intravascular ultrasound (IVUS). The FT was implemented to obtain a larger MLA. After the FT was repeated at three locations at up to 8-atm, a greater MLA of 27.1-mm2 was achieved without complications. Case 2 involved a 72-year-old male undergoing hemodialysis due to diabetes mellitus who presented with ischemic pain in his right limbs at rest due to severe stenosis with eccentric calcification in the distal CFA. The MLA on IVUS before and after balloon angioplasty was 10.0-mm2 and 13.1-mm2, respectively, and this result was still suboptimal. The FT was attempted and successfully yielded a greater MLA of 28.9-mm2 without complications. Restenosis has not been detected for 2 years follow-up period.ConclusionsThe FT is an effective option for treating calcified CFA lesions to achieve a larger lumen area. Long-term follow-up studies are necessary.
Highlights
We propose a novel calcified plaque modification technique, named the “fracking technique” (FT)
The FT is an effective option for treating calcified common femoral artery (CFA) lesions to achieve a larger lumen area
Of which are residual stenosis > 30% on angiography and insufficient acute gain on intravascular ultrasound (IVUS), remain after the balloon angioplasty, an 18-gauge needle (Terumo, Japan) without a plastic outer sheath is inserted into a part of the calcification that shows inadequate expansion on angiography and/or IVUS
Summary
This is the first report of our novel technique, named the “fracking technique (FT)”, to modify deep calcium with hydraulic pressure through an 18-gauge needle, which punctures calcifications to crack them, achieve greater acute luminal gain, increase vessel compliance, and restore vessel mobility, serving as a new versatile treatment option for patients. A balloon indeflator with a half concentration of contrast agent is connected to the needle, and the pressure of the indeflator is gradually increased in the area of dense calcification under angiography until a sudden drop in the pressure occurs, which indicates cracking of the calcification. The percutaneous direct needle puncture of calcified plaque (PIERCE) technique was attempted to modify the calcification (Ichihashi et al 2014), and a 7.0 × 40-mm noncompliant balloon was used to dilate the lesion with maximal pressure.
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