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• Peripheral vascular disease - including focal or long segment stenoses and/or chronic total occlusions.
• Uncorrectable bleeding diathesis
• Stenotic/occlusive disease with high thromboembolic risk
• Renal failure
• Extreme vessel tortuosity
Things to check:
• History and Physical
• Patient anticoagulation status
• Creatinine, coagulation profile
• Any prior imaging - Vascular ultrasound, CTA, MRA
• Lower extremity pulses
• Access common femoral artery of contralateral leg using micropuncture needle under US
• Advance wire centrally
• Place a 5, 6 or 7 Fr sheath (depending on the potential atherectomy device).
• Advance flush catheter over the wire into the aorta.
• Perform AP aortogram - 15 mL/sec for 30 mL.
• Pull flush catheter back into the distal aorta
• Perform iliac artery arteriogram - 10 mL/sec for 20 sec.
• Keep catheter in distal aorta and perform lower extremity runoff arteriography - 8 mL/sec for 80 mL
• Exchange for a selective catheter and catheterize target artery.
• Position catheter proximal to lesion.
• Administer heparin bolus prior to crossing lesion (2500-5000 U)
• Gently advance guidewire across stenosis.
• If resistance is met - avoid dissection and retract wire. Redirect catheter and readvance wire until successful passage.
• Direct guidewire through central canal of lesion. Advance selective catheter over wire across the lesion
• Angiogram following lesion crossing to confirm position
• Exchange crossing guidewire for a 0.014" guidewire.
• Many options from balloon angioplasty to atherectomy
• Introduce atherectomy device over guidewire; perform atherectomy across lesion
• Inject contrast through sheath or catheter to evaluate progress. Determine if further intervention is needed. May need balloon angioplasty, or stent placement if dissection occurs.
• Remove access sheath and close arteriotomy site - closure device or manual pressure.
• Supine bedrest for 3 hours with closure device. 6 hours with manual pressure
• Arterial injury - dissection, rupture, hematoma, distal embolization, thrombosis.
• Groin complications
 Mittleider D, Russell E. Peripheral Atherectomy: Applications and Techniques. Tech Vasc Interv Radiol. 2016;19(2):123‐135. doi:10.1053/j.tvir.2016.04.005
 Wilkins LR, Sabri SS. Strategies to Approaching Lower Limb Occlusions. Tech Vasc Interv Radiol. 2016;19(2):136‐144. doi:10.1053/j.tvir.2016.04.006
 BackTable, LLC (Producer). (2017, August 16). Ep 9 - #StopTheChop [Audio podcast]. Retrieved from