Atherectomy With Multimodal Embolic Protection for Severely Calcified Femoropopliteal Lesions

Severe calcification in femoropopliteal lesions remains a clinical challenge to achieve both the technical and long-term success in endovascular therapy. Although atherectomy is an effective treatment for calcified lesions, it is associated with the risk of distal embolization, even with the use of embolic protection devices (EPDs), and currently, no definitive strategy has been established to prevent this complication. We present a case successfully treated with atherectomy under EPDs and Parodi Anti-Embolism System (PAES). We report the case of a 77-year-old man with intermittent claudication in the left leg due to a severely calcified lesion in the superficial femoral artery. To mitigate the risk of distal embolization during atherectomy, proximal protection was achieved using Optimo catheter and distal protection was provided by Filtrap device. Additionally, arteriovenous circulation was established via a venous sheath and an external filter chamber, facilitating continuous flow reversal from the artery to the vein and effectively capturing debris within the external chamber. Atherectomy was performed under this double protection system, followed by drug-coated balloon angioplasty. Completion angiography confirmed the absence of distal embolization. Multiple calcified embolic debris were successfully captured by the aspiration system, filter, and filter chamber. This case demonstrates that combining double protection with arteriovenous circulation can establish a reliable flow reversal circuit during atherectomy, effectively preventing distal embolization. This strategy may offer an enhanced protection method for the atherectomy treatment of severely calcified femoropopliteal lesions.