Feasibility and safety of proximal anterior tibial artery direct puncture with a needle technique for the ostium occlusion with severe calcification

Background Although endovascular therapy is often used for revascularization in patients with chronic limb-threatening ischemia, highly calcified lesions below the knee still remain challenging and difficult to treat. To treat such lesions, a hard-tip guidewire or a bidirectional approach can be used to aid the passage of the guidewire and thereby perform balloon dilatation. In contrast, when a severe calcified lesion is present at a highly flexural area, such as the origin of the anterior tibial artery (ATA), passing the guidewire is extremely difficult because the route of the guidewire is restricted. Case report A male patient in his 60 s with Rutherford 5 peripheral artery disease presented with resting pain in the right foot, gangrene of the right fifth toe, and an ulcer due to stasis dermatitis near the right heel. Lower limb angiography revealed severe stenosis with calcification of the right popliteal artery and tibio-peroneal trunk (TPT) as well as obstruction with severe calcification in the ATA. Herein, we have proposed this technique—ProxiMal Anterior tibial artery direct puncture with Needle (P-MAN) for recanalizing highly calcified obstructive lesions. Discussion When a severe calcified lesion is present at a highly flexural area, such as the origin of the ATA, by directly puncturing the severe calcified portion of the ATA origin with a needle from the body surface, the calcification can be penetrated and cracked, and devices such as guidewires and balloons can pass through the lesion.