Rotational atherectomy via retrograde popliteal access without embolic protection for complex femoropopliteal lesions

Our study aims to evaluate the technical feasibility and safety of retrograde popliteal artery access (RPA) combined with rotational atherectomy and drug-coated balloon (DCB) angioplasty for complex femoropopliteal lesions, specifically without the use of distal embolic protection devices (EPD).

This single-center, single-operator, retrospective study enrolled 22 consecutive patients with TASC B and C femoropopliteal lesions treated between January 2021 and June 2025. All had severe claudication (Rutherford class 3) and calcified lesions. All underwent ipsilateral retrograde popliteal access, JetStream rotational atherectomy, and Ranger DCB post-dilatation (Boston Scientific) without embolic protection. Technical success, access-site safety, ankle-brachial index (ABI), and 12-month patency were evaluated.

Mean age was 69.9 ± 7.9 years; 18 (81.8%) were male. Technical success was 95.5% (one bailout stent). No embolic events, procedure-related deaths, amputations, or major complications occurred. One patient (4.5%) had a minor access-site hematoma. At 12 months (19 patients), Kaplan-Meier analysis demonstrated a primary patency rate of 89.9% and a secondary patency rate of 100% (as all TLRs were successful). Two patients required clinically driven target lesion revascularization (TLR) at 6 and 10 months; freedom from TLR at 12 months was 89.9%. Mean ABI improved from 0.47 ± 0.07 to 0.85 ± 0.11 at 1 month (P < .001) and remained stable at 12 months (0.86 ± 0.04).

RPA combined with rotational atherectomy and DCB angioplasty without embolic protection was technically feasible and did not result in clinically detectable macroembolization. However, definitive conclusions regarding microembolic safety cannot be drawn from these data alone.