Calcified PAD presents significant procedural challenges with heightened risk of dissection, occlusion, and perforation. The study  presented at AHA Scientific Sessions 2025 showed significant procedural success and favorable safety profiles for LA and OA performed through pedal arterial access.

This single-center retrospective cohort included 259 adults with Rutherford class 3-4 PAD treated between 2021 and 2024. Pedal access was obtained using ultrasound guidance through the anterior tibial, posterior tibial, or peroneal artery. Technical success was defined as residual stenosis <30% with no in-laboratory complications. Periprocedural events included arterial occlusion, dissection, perforation, and pseudoaneurysm. Secondary outcomes included 1-year amputation, mortality, emergency department (ED) visits within 1 week, and procedure duration.

Technical success reached 100% with LA and 99.5% with OA (P < .01). Periprocedural complications occurred in 4.9% of LA and 6.1% of OA procedures. At 1 year, amputation occurred in 3.3% vs 0.5%, and mortality in 1.6% vs 4.5% for LA and OA, respectively. ED visits occurred in 0% vs 2.5%. Mean procedure time was 66 ± 35 minutes with LA vs 61 ± 25 minutes with OA. Logistic regression showed no significant difference in adjusted complication risk (odds ratio 0.83; 95% CI, 0.27–2.53; P = .75).

Access-site events were minimal, with 1 minor dissection (1.6%) and no hematoma, pseudoaneurysm, retroperitoneal bleeding, or intervention-requiring hemorrhage.

These findings confirm pedal-access atherectomy as a safe and effective strategy for managing complex calcified PAD. Selection between LA and OA may be driven by lesion characteristics and procedural requirements.