Severely calcified lesion is one of the most difficult cases for EVT (Endovascular Treatment). Calcified nodule  known as protruding calcification is also particularly challenging in the field of EVT due to poor dilatation and healthy mesial damage resulting in a high  restenosis rate. In addition, it is necessary to get adequate pre-dilation before using Drug Eluting Balloon (DCB) in joint sites such as the femoral or popliteal  artery where Drug Eluting Stent (DES) is not an option. We have found that eccentric calcification is a major obstacle in patients who require a femoral artery access site for the treatment of structural heart disease (SHD) such as TAVI (Transcatheter  Aortic Valve Implantation). Therefore, we propose a new aggressive flossing method, Crosser® + E-VAC system "CROSSVAC" which enables us to reduce the volume of eccentric calcification and achieve sufficient lesion expansion. First, E-VAC (thrombus aspiration catheter) is inserted into  the lesion, then Crosser® is inserted into it. The tip of the E-VAC is bent at  an angle, the short end is rotated toward the calcification and move both back  and forth simultaneously. In a lesion with large vessel, balloon dilation is  performed on the opposite side of the lesion to allow the floss to be more  closely aligned with the calcification. Furthermore, E-VAC also straightens  curved small and medium vessels, allowing the Crosser® to be used more  effectively.We will show the procedures and efficacy in our hospital.　

We performed the CROSSVAC method for 24 patients with severe eccentric calcified lesions  from September 2019 to January 2022. The Study design was a retrospective, non-randomized study. The primary composite outcome was technical, angiographic success rate and complications, major secondary outcomes was the minimum lumen  area of the lesion as measured by IVUS (Intravascular Ultrasound) or OFDI (Optical Frequency Domain Imaging). 

Results showed that technical and  angiographic success rates were both 100%. In 15 cases, IVUS or OFDI were used  and the MLA at the lesion was significantly larger in the CROSSVAC method compared to Crosser® alone (4.4±2.8mm vs 9.9±6.9mm; p=0.001).  After balloon dilation, the MLA was even significantly enlarged (9.9±6.9mm vs 17.8±9.7mm; p<0.001).

In conclusion, “CROSSVAC” is a new and aggressive flossing method which is extremely useful to reduce eccentric calcification and get enough modification and lower risk of complication is expected.