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A severely calcified lesion is the most challenging entity in endovascular therapy (EVT) for below-the-knee (BTK) arteries. In this report, we introduce a challenging plaque modification technique known as the inner PIERCE technique. A 65-year-old man on hemodialysis with multiple toe ulcerations underwent an EVT for his BTK artery diseases. During EVT, the guidewire passed through the severely calcified posterior tibial and plantar arteries; however, the other devices could not pass through the lesion. Therefore, a novel inner PIERCE technique was performed. After guidewire externalization, an 18G 20 cm needle was advanced from the retrograde approach site, following the guidewire, for percutaneous transhepatic cholangiodrainage (PTCD). The PTCD needle was advanced into the severely calcified plaque using a rotational motion. Finally, the needle could pass through the lesion. After the inner PIERCE technique, an angioplasty was performed with a 2.5 mm balloon. The final angiography showed sufficient blood flow. After the EVT, complete wound healing was achieved in 4 months. This challenging technique may be an additional option for EVT to treat severely calcified BTK arteries.

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Endovascular therapy, an established first‐line treatment for isolated iliac artery (IA) occlusion (IAO), may be of limited use in challenging lesions. We describe a novel percutaneous endoluminal anatomical bypass (PEApass) technique for uncrossable external IA (EIA) occlusion. A 70‐year‐old man on hemodialysis with a history of colostomy presented with chronic limb‐threatening ischemia due to a left EIA with below‐the‐knee occlusions. During a previous colostomy, the left EIA was accidentally ligated. Conventional endovascular recanalization for the ligated EIA failed, and a femoral‐femoral bypass and below‐knee angioplasty were performed as alternative therapy. Two weeks later, surgical site infection developed at both anastomosis sites. PEApass was performed prior to removing the infected graft. An arteriovenous fistula (AVF) in the distal location was created using a re‐entry device, and its proximal location was created using a 0.014‐in. penetration guidewire, which was snared on the inside of the iliac vein (IV) using a retrograde snare. The proximal and distal sections of the IA were connected using an 8.0‐mm × 100‐mm stent graft implanted through the IV. A final angiogram indicated that flow to the occluded IA was completely restored without complications. Following the PEApass, the infected graft was removed. Complete wound healing was achieved within approximately 1 month. This innovative PEApass procedure is feasible and could be an alternative procedure for patients with uncrossable IAO.

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