The "Fracking" technique: a novel approach to crack deep calcified plaque in the common femoral artery with hydraulic pressure

Takuya Haraguchi; Tsutomu Fujita; Yoshifumi Kashima; Masanaga Tsujimoto; Tsuyoshi Takeuchi; Yutaka Tadano; Daisuke Hachinohe; Umihiko Kaneko; Ken Kobayashi; Daitaro Kanno; Katsuhiko Sato

doi:10.1186/s42155-021-00258-y

The "Fracking" technique: a novel approach to crack deep calcified plaque in the common femoral artery with hydraulic pressure

CVIR Endovasc. 2021 Sep 27;4(1):70. doi: 10.1186/s42155-021-00258-y.

Affiliations

¹ Director of Cardiology and Head of Peripheral Artery Disease Center, Sapporo Heart Center, North 49, East 16, 8-1, Higashi ward, Sapporo, Hokkaido, 007-0849, Japan. t.haraguchi@scvc.jp.
² Director of Cardiology and Head of Peripheral Artery Disease Center, Sapporo Heart Center, North 49, East 16, 8-1, Higashi ward, Sapporo, Hokkaido, 007-0849, Japan.

Abstract

Background: The patency achieved by conventional peripheral interventions for atherosclerotic lesions in the common femoral artery (CFA), called the "no stenting zone", is not superior to that achieved by surgical endarterectomy due to calcified plaque occupying the area. Plaque modification strategies to obtain acute gain in CFA patency provide the better clinical outcomes than standard balloon angioplasty. Atherectomy devices, which focus on the modification of superficial calcifications, contribute to the improvement of clinical outcomes. However, deep calcifications resist vessel expansion such that luminal gain is not easily achieved.

Main text: We propose a novel calcified plaque modification technique, named the "fracking technique" (FT). The term fracking refers to how a rock is fractured by the high hydraulic pressure. In this technique, deep calcifications are cracked with hydraulic pressure via a balloon indeflator through an 18-gauge needle, which punctures calcifications to achieve greater acute luminal gain. Case 1 involved an 81-year-old male with eccentric calcified plaque in the right CFA. Conventional balloon angioplasty for the lesion yielded a suboptimal minimal lumen area (MLA), which increased from 6.2 to 10.7-mm² on intravascular ultrasound (IVUS). The FT was implemented to obtain a larger MLA. After the FT was repeated at three locations at up to 8-atm, a greater MLA of 27.1-mm² was achieved without complications. Case 2 involved a 72-year-old male undergoing hemodialysis due to diabetes mellitus who presented with ischemic pain in his right limbs at rest due to severe stenosis with eccentric calcification in the distal CFA. The MLA on IVUS before and after balloon angioplasty was 10.0-mm² and 13.1-mm², respectively, and this result was still suboptimal. The FT was attempted and successfully yielded a greater MLA of 28.9-mm² without complications. Restenosis has not been detected for 2 years follow-up period.

Conclusions: The FT is an effective option for treating calcified CFA lesions to achieve a larger lumen area. Long-term follow-up studies are necessary.

Keywords: Atherectomy; Balloon angioplasty; Calcified plaque; Common femoral artery; Endarterectomy; Endovascular intervention; Intravascular lithoplasty; Intravascular ultrasound; Peripheral arterial disease.