Sequential dual rotational atherectomy for salvage of a 20-year axillobifemoral PTFE graft.

Salvaging chronically occluded extra-anatomical bypass grafts remains challenging given prohibitive surgical risk. We describe sequential dual rotational atherectomy for a completely occluded 20-year axillobifemoral PTFE graft in a 73-year-old high-risk woman with hostile abdominal anatomy, Trans-Atlantic Inter-Society Consensus D aortoiliac occlusion, chronic kidney disease, and prohibitive surgical mortality (8%-15%). Staged approach employed Phoenix 2.2-mm atherectomy for calcified plaque and Jetstream 2.4-mm atherectomy for organized thrombus with a 5-day interval for renal protection. Ankle-brachial indices improved from 0.35 to 0.65 to 0.84 to 1.00, ambulation increased from <50 m to >350 m, achieving sustained secondary patency at the 24-month follow-up.