Severely Calcified Proximal Superficial Femoral Artery Lesion Treated With Bamboo Spear Technique Under Complete Ultrasound Guidance: A Case Report

Introduction

Endovascular therapy (EVT) has become the first-line treatment for peripheral artery disease across most vascular territories. However, common femoral artery (CFA) endarterectomy remains the therapy of choice for the femoral region because of its favorable long-term outcomes [1,2]. Surgical intervention carries risks such as infection and lymphatic complications, making EVT a viable alternative in selected patients. Recent studies suggest that stent-based EVT in the femoral region can yield favorable outcomes [3]. Nevertheless, heavy eccentric calcifications often prevent adequate lesion expansion. In such cases, precise guidewire passage through the center of the calcified nodule is essential.

The bamboo spear technique [4] involves direct puncture of the calcified lesion with a bare-metal needle, followed by guidewire insertion and balloon angioplasty. The use of ultrasound (US) guidance further enhances the accuracy of this technique. We present a case of successful EVT for a subocclusive lesion of the proximal superficial femoral artery (SFA) with severe calcified nodules using the bamboo spear technique under complete US guidance.

Case Report

A 60-year-old man on chronic hemodialysis presented with severe intermittent claudication of the left leg. The patient had a history of hypertension, dyslipidemia, and diabetes mellitus. Intermittent claudication occurred after approximately 50 m of walking. Although cilostazol was administered, his symptoms did not improve. His ankle-brachial index was reduced to 0.75. Computed tomography and angiography revealed a subocclusive lesion with dense calcification in the proximal SFA (Figure 1). The patient refused surgery, and EVT was planned.

The patient’s body mass index was 23 kg/m2, and groin adiposity was mild. Therefore, direct puncture of the lesion was considered technically feasible, and the bamboo spear technique was selected. A 6-Fr guiding sheath (Destination®, Terumo) was inserted into the left CFA through a contralateral approach. A 20-G metal introducer needle (Medikit) was used to puncture the distal portion of the calcified lesion. Under longitudinal US guidance (Figure 2A), the needle was carefully advanced toward the center of the calcified nodule (Figure 2B–2D); its trajectory was intermittently confirmed using short- and long-axis views (Figure 2E, 2F). A 0.014-inch guidewire (Gladius MGES®, Asahi Intec) was inserted through the needle and advanced into the guiding sheath, completing an externalized wire loop (Figure 3A–3D).

In this technique, central passage through the calcified nodule must be achieved to obtain sufficient lumen gain. In addition to external US, the use of intravascular ultrasound (IVUS) enabled precise visualization of the needle and wire trajectory through the center of the lesion. After a 3.0×40 mm balloon had been used for predilation, IVUS confirmed that the wire had passed precisely through the center of the calcified plaque (Figure 3E, 3F). A 7.0×40 mm scoring balloon (Lacrosse NSE®, Nippro) was then utilized, after which hemostasis of the retrograde puncture site was achieved (Figure 3G). A 7.0×40 mm drug-coated balloon (IN.PACT®, Medtronic) was subsequently inflated (Figure 3H). Final IVUS confirmed an adequate lumen area (Figure 3I), and angiography demonstrated excellent patency with complete resolution of the pressure gradient (Figure 3J). The ankle-brachial index improved to 0.98, and claudication resolved. The total procedure time was 90 minutes, and the fluoroscopy time was 16 minutes, both within an acceptable range. Dual antiplatelet therapy was continued after the procedure, and the patient was discharged on postoperative day 4.

Discussion

We successfully used the bamboo spear technique under complete US guidance to puncture a heavily calcified lesion in the proximal SFA and achieve central guidewire passage. In cases of severe calcification, standard balloon angioplasty often fails to achieve sufficient luminal gain and carries a risk of vessel perforation. Alternative techniques for penetrating calcified plaques include the aggressive wire recanalization in calcified atheroma and dilatation (ARCADIA) technique [5], balloon-backed microcatheter technique [6], and fracking [7]. Some specialized devices are available; however, their use may be restricted by insurance coverage and facility limitations. These techniques often encounter difficulty in penetrating heavily calcified lesions. Our method allows direct mechanical penetration using a bare-metal needle, which is substantially stiffer and sharper than a guidewire.

A key technical aspect of this procedure is appropriate US guidance. Maintaining long-axis visualization of the vessel allows the operator to direct the needle toward the vascular center, whereas short-axis imaging enables real-time confirmation that the needle is consistently advancing through the central portion of the calcified nodule. These advantages of US guidance contribute to procedural accuracy and safety. Externalization of the wire through an antegrade sheath also reduces wire tension and the risk of needle dislodgment. Once passage is achieved, scoring or cutting balloons can be used in conjunction with high-pressure balloons to ensure expansion. Although short-term success was achieved in the present case, long-term outcomes remain unknown. The stenting of CFA or proximal SFA lesions may improve durability [3,8]; however, it can limit future access because of difficulties associated with re-puncture. The safety and efficacy of this technique require validation in larger studies. Technical limitations may arise in patients with obesity or when targeting long lesions due to needle length and angle constraints. Acoustic shadowing may also hinder US visualization in such cases. Current guidelines mainly recommend surgical endarterectomy or standard balloon angioplasty for calcified nodules in the CFA and proximal SFA. However, standard balloon angioplasty often fails to achieve sufficient luminal gain in heavily calcified lesions, as in the present case. Compared with the ARCADIA technique, the bamboo spear technique allows more intentional and accurate wire passage through the center of the calcified core, which may facilitate subsequent expansion. In contrast, fracking may leave residual eccentric calcification, potentially limiting luminal gain. Atherectomy systems such as HawkOne or JetStream, as well as intravascular lithotripsy, are also effective options for severely calcified lesions. Importantly, these devices are not universally available across institutions and health care systems, which reduces their practicality in some regions. This technique may be appropriate in EVT candidates with poor surgical suitability.

Conclusions

Although surgical endarterectomy is the standard treatment for femoral revascularization, EVT is often required in patients with contraindications. The bamboo spear technique may be a feasible option in such cases. Complete US guidance allows precise targeting of the calcified plaque center, thereby enabling effective expansion and leading to favorable short-term outcomes.