Advanced Needle-Based Strategies for Complex Calcified Peripheral Artery Disease: A Systematic Review

Severely calcified peripheral artery disease (PAD) lesions that cannot be fully dilated by conventional balloon angioplasty pose major therapeutic challenges, especially when atherectomy devices are unavailable. Needle-based, plaque-modifying strategies have emerged as adjunctive or bailout approaches to facilitate lesion crossing and vessel expansion in such complex settings.

A systematic review was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines. Scientific databases were searched for studies evaluating needle-based interventions for heavily calcified PAD.

Fifteen studies encompassing 101 patients were included, involving techniques such as fracking (hydraulic plaque cracking), percutaneous direct needle puncture of calcified plaque (PIERCE), BAMBOO SPEAR (needle drilling method), biopsy forceps plaque extraction, and FRAP-CROSS technique. Lesions were located in the common femoral, superficial femoral, anterior tibial, and tarsal arteries. Technical success ranged from 94% to 100% across reported studies. Fracking achieved substantial minimal luminal area gains (6-10 mm² to >22 mm²), corresponding with 90% 12-month patency and 94% target lesion revascularization-free survival. PIERCE and its modifications enabled safe advancement through calcified segments refractory to conventional crossing, with minimal complications. BAMBOO SPEAR and biopsy forceps extraction provided effective plaque debulking, complete stent expansion, and 100% procedural success in reported cases. FRAP-CROSS, combining fracking and Rendezvous-PIERCE, safely facilitated wiring across calcified femoropopliteal occlusions. Adverse limb events were rare, and long-term durability appeared comparable to atherectomy-based outcomes.

Needle-based, plaque-modifying strategies appear feasible for complex calcified PAD, particularly in resource-limited settings. Further prospective studies are warranted to define optimal indications, standardize techniques, and validate long-term outcomes.