A man in his late 80s who is a recreational tennis player presented with a nonhealing, 1.5-cm wide and 0.3-cm deep right medial hallux wound. His risk factors included former smoking status and hypertension. He is maintained on 81 mg aspirin daily. ABIs were 0.5 on the right and 0.9 on the left.


The procedure began with left contralateral common femoral artery access for aortography and right lower extremity runoff arteriography. This demonstrated patent aortoiliac inflow and right femoropopliteal outflow. The posterior tibial artery was chronically occluded, and the peroneal artery was diminutive in caliber. There was diffuse disease involving the AT artery with long-segment severe stenosis proximally transitioning to CTO of the mid AT with reconstitution of the distal AT into a patent DP artery (Figure 2A and 2B). Due to severe iliac tortuosity, antegrade right proximal superficial femoral artery access was obtained and a 6-
F, 45-cm Destination sheath (Terumo Interventional Systems) was placed. The AT CTO was recanalized using a 0.014 Glidewire Advantage (Terumo Interventional Systems) and 0.018-inch NaviCross catheter (Terumo Interventional Systems), and AT predilation was performed using a 2- X 100-mm PTA balloon. Subsequently, a 3- X 120-mm Serranator PTA balloon was inflated slowly to 6 atm for 2 minutes across the recanalized AT segment (Figure 2C). Completion arteriography demonstrated widely patent AT and DP with increased perfusion to the target hallux wound bed (Figure 2D and 2E).


The Serranator balloon delivered an excellent angiographic result, far superior to what would be expected for POBA of long-segment tibial disease. The patient’s wound healed completely by 4 weeks and he resumed playing tennis.

Are these results described in your cases typical for CLTI interventions?

Drs. Zimmermann and Leung: Satisfactory angiographic results are not consistently obtained with POBA alone despite meticulous sizing and prolonged inflation times. In our experience, serrated balloon angioplasty delivers consistently good results with decreased rates of flow-limiting dissection and vessel recoil compared to POBA, especially when treating heavily diseased BTK lesions, thus reducing the need for bailout stenting.

What is your inflation technique?

Drs. Zimmermann and Leung: Like with many endovascular devices, “go slow to finish fast.” With slow, con- trolled inflation, lesions will typically open well under nominal balloon pressure.

Why have you added the Serranator PTA balloon into your treatment algorithm?

Drs. Zimmermann and Leung: The Serranator PTA balloon fills a gap in the BTK treatment that was lacking with POBA alone. We’ve experienced consistently good results in terms of luminal gain and distal perfusion with a decreased need for post balloon scaffold placement. With its unique mechanism of action, the available Serranator PTA is well suited for the various BTK lesion morphologies encountered in CLTI patients and would likely be suitable for vessel prep before drug-coated balloon angioplasty.

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