From Flossing to Fracturing – Subintimal Lithotripsy for Recoil Stenosis Modification Prior to Interwoven Stent Implantation

A 67-year-old man with chronic limb-threatening ischaemia (CLTI) and a heavily calcified superficial femoral artery (SFA) chronic total occlusion underwent subintimal recanalisation using SAFARI approach after failed antegrade crossing. Predilation caused severe recoil from eccentric calcification. Intravascular lithotripsy (300 pulses at 4 atm) was delivered within the subintimal plane, followed by ultra-high-pressure balloon angioplasty and implantation of an interwoven nitinol stent, achieving <30% residual stenosis. At three months, duplex ultrasound confirmed stent patency without fracture, and the wound had healed. This case adds to the limited experience with subintimal intravascular lithotripsy as a vessel preparation strategy for calcified recoil lesions.