- Relevant clinical history and physical exam:
A 68 years old man presented with claudication which started eight months ago. He had operations of CABG and endarterectomy at left internal carotid artery. He had smoked one pack of cigarette daily for past 30 years. His medical history was significant for hypertension and hypercholesterolemia. His current medications were antihypertensive medications and lipid lowering agents. He had an angioplasty on his left SFA (superficial femoral artery) seven months ago. After treatment with stent at left SFA, his symptom disappeared but right leg pain continuously bothered him. He was admitted to treat his right SFA.

- Relevant test results prior to catheterization:
The CT angiography showed the occlusion of both superficial femoral arteries (SFA) during his first admission. The result of segmental limb pressure with doppler revealed a significant Rt. SFA disease with a pressure dropping of more than 20 mmHg compared to the same segment horizontally.(Figure 1)

- Relevant angiography findings:
Total occlusion of right SFA with heavy calcification was shown ( Movie 1).

- Procedural step:
We inserted into the Left femoral artery (retrograde approach) with a 7 Fr sheath. The 0.032” Terumo wire was crossed from left common iliac artery to right iliac artery by using right JR 3.5 (5 Fr). We changed from the JR 3.5 to the Shuttle (7 Fr) and inserted MPA (5Fr).(Figure 2) However, the 0.035” Terumo wire failed to pass through the total occluded lesion of right SFA. Therefore he used right JR 3.5 (5 Fr) again and finally had the 0.035” Terumo wire gone through the lesion and advanced it by subintimal approach. Then, percutaneous transluminal angioplasty was done with using a 80 x 4.0 mm POWERFLEX balloon. Two SMART stent (7.0 x 150 mm, 6.0 x 150 mm) were successfully deployed with overlapping.( Movie 2) Despite post-dilatation with a 6.0 x 80 mm POWERFLEX balloon, the distal stent within the high calcified lesion was under-expanded. A 6.0 x 150 mm balloon-expandable Express LD stent was deployed at that lesion.(Figure 3) Final angiogram showed the stent not fully expanded but a good distal blood flow.( Movie 3)