Peripheral arterial disease (PAD) is a clinical sign of systemic arteriosclerosis and is associated with significant morbidity and mortality. The endovascular approach, compared to the surgical approach for revascularization of PAD, is known to be associated with a higher restenosis rate and a greater need for repetitive intervention. To overcome this limitation, various endovascular devices, including drug-coated balloons and drug-eluting stents, have been developed. Among these, transluminal atherectomy could be an appropriate choice for debulking and vessel preparation for severely calcified lesions.

The Jetstream™ Atherectomy System (Boston Scientific) is a rotational atherectomy device commonly used for vessel preparation in lower-extremity percutaneous transluminal angioplasty. However, atherectomy is not a risk-free procedure and is associated with various complications. Known complications of Jetstream™ atherectomy include device entrapment on the guidewire (27%), loss of blade rotation (23%), loss of aspiration (20%), mechanical damage (11%), embolism (4.4%), dissection (3.4%), vessel perforation (2.4%), and device fracture (1.2%); however, delayed pseudoaneurysm formation is very rare [1].

We report the case of a patient with a delayed rupture and pseudoaneurysm of popliteal artery (PA) after uneventful Jetstream™ atherectomy. This study was approved by the Institutional Review Board of the Pusan National University Yangsan Hospital (55-2024-008). The board waived the requirement for informed consent.

A 73-year-old man with a history of hypertension, diabetes, and cerebral infarction visited an outpatient clinic due to intermittent claudication (Rutherford category 3) in both lower limbs, with particularly severe pain in the right calf during walking. The ankle-brachial index (ABI) measured in the outpatient clinic was 0.76 on the right ankle, and a subsequent duplex ultrasound showed diminished PA flow at the P3 segment. Computed tomography angiography (CTA) identified severe calcification (Peripheral Arterial Calcium Scoring System grade 4) at P2 segment of the right PA (Fig. 1) [2].

Figure 1. The patient’s computed tomography images of lower extremity. (A) Severe calcification in right popliteal artery in an axial image, (B) A 4 cm long calcified lesion in a three-dimensional reconstruction image.

For revascularization of the right leg, rotational atherectomy using a Jetstream™ atherectomy device was chosen for debulking and vessel preparation. Intraoperative angiography revealed a chronic total occlusion at the P2 level. After successful wire passage, we performed Jetstream™ (XC 2.4-3.4) atherectomy, followed by drug-coated balloon angioplasty with a 6.0 mm×150 mm IN.PACT Admiral balloon (Medtronic, Inc.) (Fig. 2). No contrast leakage, distal embolization, or other complications were observed on the final angiogram obtained immediately after angioplasty (Fig. 2D). Postoperatively, the symptoms in the lower extremities were relieved, and the ABI improved to 0.99. There were no major adverse events, and the patient was discharged with a prescription of 100 mg aspirin and 200 mg cilostazol on the third day of treatment.

Figure 2. Angiography during the procedure. (A) The popliteal artery showed a total occlusion due to severe calcified atheroma. (B) Jetstream™ rotational atherectomy was performed to debulk the calcified lesion. (C) Angiography after atherectomy demonstrated recanalization of the occluded segment. (D) Final angiography after drug-coated ballon angioplasty showed a well-patent popliteal artery without contrast leakage.

On the 6th postoperative day, the patient visited the emergency room with severe pain and swelling in his right calf. The pain was so intense that he could not walk with his right leg. The follow-up hemoglobin had decreased to 9.5 mg/dL from 11.1 mg/dL of preoperative value, and a pseudoaneurysm (24 mm×20 mm×27 mm) with PA rupture was detected on CTA (Fig. 3). Emergency surgery was performed under the suspicion of a ruptured PA and compartment syndrome. The PA was exposed through a longitudinal incision into the right popliteal fossa with the patient in the prone position. It was difficult to secure a field of view because of massive bleeding during the operation. After identifying the rupture, the proximal and distal PAs were dissected and isolated, and flow was blocked using a vessel loop. The anterior wall of the PA was found to be ruptured and was identified after a longitudinal incision of the posterior wall, revealing severely calcified intimal plaques. Primary repair was performed on the anterior wall, and bovine patch angioplasty was performed on the incision site of the posterior wall after endarterectomy (Fig. 4). The hematoma of the popliteal fossa was evacuated, and surgery was completed after the insertion of a Jackson-Pratt drain.

Figure 3. Follow-up computed tomography of lower extremity at the emergency room. (A) Axial image revealed a rupture with pseudoaneurysm formation in the right popliteal artery. The diameter of pseudoaneurysm was measured as 24 mm×20 mm×27 mm. (B) A three-dimensional reconstruction image also showed the popliteal artery rupture.

Figure 4. Intraoperative photograph. (A) After bleeding control and posterior incision of the popliteal artery. (B) Anterior rupture site of the popliteal artery after endarterectomy. (C) Resected atheroma.

One week postoperatively, his symptoms abated, and he was discharged without complications. Three years after the surgery, the patient still had an ABI of 1.1/1.2 with satisfactory working.

Atherectomy for femoropopliteal disease has been shown to modify vessel compliance, allowing adjunctive percutaneous transluminal angioplasty to occur at low pressure with limited dissections and reduced need for bailout stenting. In addition, preclinical studies have shown that atherectomy improves paclitaxel concentration and diffusion into arteries with moderate to severe calcification [3]. Therefore, atherectomy has been proposed and widely used for vessel preparation before drug-coated balloon angioplasty for calcified femoropopliteal lesions.

Rotational atherectomy devices feature cutting blades that rotate at high speeds, thus inducing differential cutting of the atheroma while preserving the elastic tissue wall of the uninvolved vessel. The Jetstream™ Atherectomy System has five expandable rotating blades with an active aspiration function for the preemptive removal of scraped plaque, which minimizes the risk of distal embolization [3]. Zeller et al. [4] reported a 99% device success rate with Jetstream™ atherectomy and 6-month and 12-month target-lesion revascularization rates of 15% and 26%, respectively. The 1-year restenosis rate was reported as 38.2 % [4,5]. Additionally, atherectomy has been reported as a predictor of low amputation rates in various subgroups, including those with chronic limb ischemia (odds ratio, 95% confidence interval [CI], P-value; 0.74, 0.59-0.93, 0.010), angioplasty (0.72, 0.60-0.87, 0.001), and patients with a high burden of baseline comorbidities (0.82, 0.69-0.99, 0.035) [6].

Despite the possible advantages of rotational atherectomy, various complications are associated with it. Abrupt vessel occlusion, dissection, distal emboli, hematoma at the access site, infection, perforation, pseudoaneurysm, renal failure, restenosis, and thrombus formation are some of the reported complications of Jetstream™ atherectomy [7]. Among these complications, distal embolization and dissection are the most common complications [7]. Sixt et al. [5] reported emboli (13.8%) and dissections (8.8%) after rotational atherectomy for femoropopliteal occlusive disease. In the Zeller et al. [4] study, minor embolic events were noted in 10% of cases, and 9% of cases were complicated by dissection. Vessel perforation and pseudoaneurysm formation are relatively rare complications after rotational atherectomy. In a previous study of Sixt et al. [5], the incidence of pseudoaneurysms and perforations was both reported at 2.5%. Additionally, Zeller et al. [4] reported 4 perforations (2%) in 172 patients. However, all these events were detected intraoperatively and successfully managed during the index procedure. Minor perforations (contrast effusion around the vessel) were sealed with prolonged balloon dilation, and no cases required covered stents [4].

Recently, Asian studies have also reported complications. The J-SUPREME trials indicated extremely low 1-month major adverse events (MAEs) (0%), with no distal embolization or perforations [8]. In a Korean multicenter study involving 150 patients, the 30-day MAE rate was 5.3%, including technical failures, arterial perforations or dissections, acute thrombi, and distal embolization. Among them, arterial perforation rate was 1.3% (2/150), and both patients were successfully managed using prolonged balloon tamponade [9].

Therefore, delayed rupture and pseudoaneurysm formation can be considered as rare complications of rotational atherectomy. Delayed pseudoaneurysm formation after directional atherectomy has been reported in several case reports [10,11]; however, delayed rupture and pseudoaneurysm formation after rotational atherectomy are extremely rare [12]. Mechanical factors have been implicated as the causes of vessel wall trauma during atherectomy. These include the tortuous nature of the vessel, an oversized atherectomy device, lesions close to a prior surgical scar, and the location of the lesion near the side branches [13]. These factors can lead to a deeper cut than intended for a diseased vessel.

In our patient, delayed pseudoaneurysm development was likely due to inadvertent atherectomy of the disease-free intima near the target lesion, even with the correct use of an appropriately sized atherectomy device. During the operation, the wire was passed eccentrically through the lesion, followed by rotational atherectomy. Subsequent balloon angioplasty can further injure the damaged intima. The weakened arterial wall, combined with the high shear force from the adjacent blood flow, could have weakened and ruptured arterial wall. Therefore, in cases of eccentric wire passage in heavily calcified lesions, rotational atherectomy should be performed cautiously, and subsequent excessive balloon angioplasty with a large diameter should be avoided to prevent this complication.

Traditionally, peripheral pseudoaneurysms have been treated with open surgical repair to effectively mitigate thromboembolic risk [14]. However, endovascular treatment has gained popularity owing to reduced blood loss, shorter hospital stays, and quicker recovery [15]. Evidence supports the feasibility and durability of Viabahn stent grafts for anatomically suitable PA aneurysms [16]. Pooled primary and secondary patency rates were 69.4% (95% CI 63.3% to 76.2%) and 77.4% (95% CI 70.1% to 85.3%), respectively, at 5 years [16]. In our case, as the supply of Viabahn ended in Korea, it was difficult to find a covered stent to replace it, and the patient’s symptoms were severe, leading to prompt intervention because of the suspicion of compartment syndrome. Hence, surgical repair was performed to treat the popliteal pseudoaneurysm in this patient.

In summary, it is important to be aware of rare complications as endovascular therapy for PAD has become increasingly common. Delayed arterial rupture with pseudoaneurysm formation after Jetstream™ atherectomy is a potential complication. This can be prevented through the evaluation of mechanical and anatomical factors before surgery, and prompt management is required to prevent devastating outcomes after development.

None.

The authors has nothing to disclose.

Concept and design: all authors. Analysis and interpretation: all authors. Data collection: all authors. Writing the article: all authors. Critical revision of the article: all authors. Final approval of the article: SSL. Obtained funding: none. Overall responsibility: SSL.