A 77-year-old patient with chronic limb-threatening ischemia and heavily calcified femoropopliteal disease. The popliteal occlusion was so dense that Mariano called it a rock. On Life of Flow, Miguel and I sat down with Dr. Mariano Palena for Case Cast 2. He did this case live, the fourth live case of CLICK 2024, tired after three complex cases, and asked the experts in the room for help. One of them, Dr. Ferraresi, suggested palliative care. On paper, it was a no-option limb.
When Calcium Looks Like No Options
Mariano Palena brings a 77-year-old CLTI case with dense femoropopliteal calcium. How we'd cross it, prep it, and judge whether the foot got enough flow.
Watch The Episode
When Calcium Looks Like No Options: A Limb-Salvage Case with Mariano Palena, LOF #136 of Life of Flow, hosted by Dr. Lucas Ferrer and Dr. Miguel Montero-Baker.
Dense Calcium, Real Options
Mariano tried anyway. His reasoning comes from the SUPERSUB studies his group published. Go around the calcium in the subintimal space, prepare hard with a high pressure balloon, and you can build a new lumen that works.
He also noted that the first angiogram undersold the foot. Once flow came down, there was more there than anyone saw at the start.
Decide Early
He went subintimal from the first pass with a stiff angled 035 wire. Once past the popliteal, he went retrograde through the peroneal. Both sites were connected, through and through, in roughly 15 to 20 minutes.
Committing to that plan early came up as one of the biggest factors in speed.
Then came prep: 4, then 5, then 6 mm, step by step, to lower the risk of rupture. He chose a Supera stent because his group hasn't seen it fracture in this position and it resists compression. Even after aggressive prep, two or three spots needed post-dilation.
Retrograde, Done Safely
Mariano punctures 5 to 6 cm below the occlusion for support, using the most proximal patent segment that reaches the target. He has had one dissection from this kind of access in almost 18 years. He's also candid that he isn't a surgeon and can't do the bypass bailout himself. His advice: if it's your first retrograde case, have someone there who can help.
Miguel learned a hard lesson once. His wire ran alongside the sheath, outside the lumen, and looked fine. He ballooned and turned a four French hole into a three millimeter one. Now he pulls the wire and shoots an image before inflating for hemostasis.
Does The Picture Answer The Wound?
The final run showed strong flow into the foot. I pushed back: no AP view, and no clear metatarsal vessel to the wound. A pretty picture can send a patient to amputation while the wound stays ischemic.
Miguel's line: angiographic beauty is second to hemodynamic improvement. Stop, get an ultrasound in a couple of days, check pedal acceleration times. Mariano said the patient did well, and the foot surgeons' necrectomy was enough.
The Takeaway
Calcium doesn't settle the options question. A good final angiogram doesn't settle perfusion.
Know what you can rescue before you take the next step.