A 68-year-old male with sudden pain in his left lower limb was referred to our clinic for further evaluation and treatment. He had a history of surgical thrombectomy and superficial femoral artery-posterior tibial artery bypass for acute limb ischemia on his right leg. Although there were no motor or sensory impairments in the left lower leg, his foot appeared cyanotic and felt cold. Arterial pulses could not be palpated below the knee, the left ABI (Ankle-Brachial Index) was unmeasurable.

Contrast-enhanced CT revealed a thrombus in the proximal portion of the left superficial femoral artery (SFA), complete thrombotic occlusion from the middle part of the SFA to the proximal portion of the popliteal artery (POPA), and residual thrombi even from the middle part of POPA to the tibioperoneal trunk (TPT) (Figure 1). It was diagnosed as acute lower limb arterial occlusion (Category I).

On the 5th day of hospitalization, an endovascular treatment (EVT) was performed. As well as contrast-enhanced CT, initial angiography revealed complete thrombotic occlusion from the middle part of the SFA to the proximal portion of the POPA, and residual thrombi even from the middle part of POPA to the TPT.

A 7-french guiding sheath was inserted retrogradely from the left common femoral artery, and aspiration was attempted using a 6-french aspiration catheter. Although a small amount of red thrombus was removed (Figure 2), angiography revealed severe stenosis and slow flow remained (Figure 3). Intravascular ultrasound (IVUS) revealed a significant amount of thrombus with slightly increased brightness from the proximal part of the superficial femoral artery (SFA) to the tibiofibular trunk (TPT). Therefore, the thrombus within the SFA was sealed using a bare nitinol stent. Attempts were made to move the thrombus from POPA to TPT using a Fogarty catheter repeatedly, however, some residual thrombus that couldn't be completely sealed dispersed into the TPT (Figure 4).Efforts were made to aspirate using an aspiration catheter, crush the thrombus using a Fogarty catheter and balloons, and shift the thrombus, but these attempts were ineffective. Eventually, with the use of a biopsy forceps, after several attempts, a string-like thrombus measuring 5 cm in length was successfully removed (Figure 4D). Concluding angiography revealed no thrombus in tibio-peroneal trunk and Thrombolysis in Myocardial Infarction Ⅲ blood flow (Figure 5). The procedure was concluded. The patient's symptoms disappeared, and the left lower limb ABI improved to 1.02. Reperfusion impairment remained minimal.

 The use of biopsy forceps may be an alternative method for ALI cases when an aspiration catheter and balloon angioplasty do not work sufficiently. Thrombectomy using biopsy forceps is a feasible technique for removal of an arterial thrombus.