Trans-ankle intervention can be an optimal strategy for aggressive wire recanalization in calcified atheroma and dilatation technique in common femoral artery.

The aggressive wire recanalization in calcified atheroma and dilatation (ARCADIA) technique has been reported as a promising strategy for endovascular treatment (EVT) of severely calcified plaques in the common femoral artery (CFA). Although the technique is usually implemented via the contralateral CFA, establishing the contralateral approach system can be challenging at times. A 72-year-old man was admitted for the treatment of intermittent claudication in his right lower extremity. The patient had previously undergone EVT for a severely calcified iliac bifurcation with 2 covered stents in a kissing configuration. Subtotal occlusion due to a severely calcified plaque in the right CFA remained. We performed EVT using a trans-ankle intervention (TAI) strategy for this complex pathological entity. First, we punctured the right dorsalis pedis artery under extravascular ultrasound guidance and inserted a guiding sheath into the distal part of the target lesion. The first guidewire was passed through the subtotal occlusion. Parallel guidewire manipulation with a second guidewire using a dual-lumen catheter was performed and successfully passed into the intraluminal space of the external iliac artery. After lesion preparation with optimal balloon dilation via both guidewire routes, the procedure was successfully finalized using drug-coated balloon dilation. The novelty of our case lies in the application of TAI using the ARCADIA technique. As the TAI strategy provides a variety of benefits in overcoming several challenging issues in implementing the ARCADIA technique, it is thought to be an optimal option for achieving better outcomes with the ARCADIA technique.