Managing Procedural Complications During Atherectomy for Chronic Limb Threatening Ischemia: A Case Report

Purpose: Critical Limb Threatening Ischemia (CLTI) is the most severe stage of Peripheral Artery Disease (PAD), characterized by ischemic rest pain, non-healing ulcers and gangrene. Despite advances in revascularization, CLTI remains associated with poor outcomes, including one-year mortality of 20% to 25% and major amputation rates up to 30%. Endovascular Therapy (EVT) is a less invasive treatment option, with atherectomy being particularly useful in calcified or occlusive lesions. However, Large Thrombus Burden (LTB) poses a major challenge due to increased risk of distal embolization. While Embolic Protection Devices (EPDs) aim to mitigate this, their efficacy in CLTI remains uncertain. Methods: A 68-year-old man with PAD presented with rest pain and a non-healing ulcer on the right fifth toe. Angiography revealed subacute occlusion of the superficial femoral artery extending to the anterior tibial artery, with suspected LTB. EVT was performed using a Jetstream atherectomy device for lesion debulking and an embolic filter for distal protection. Following successful guidewire crossing and atherectomy, the procedure was complicated by acute limb ischemia due to distal embolization in the tibioperoneal trunk. Immediate thromboaspiration was performed using the Penumbra Indigo System. Results: Thromboaspiration effectively restored distal perfusion. Post-procedural angiography confirmed full revascularization with no residual thrombus. The patient’s symptoms improved and he was discharged on dual antiplatelet therapy, with follow-up planned at 1, 3 and 6 months. Conclusion: Atherectomy in CLTI patients with LTB increases embolization risk, even with EPDs. Thromboaspiration remains a viable rescue strategy, underscoring the need for standardized protocols and further research on embolic risk mitigation.