Distal Embolization of Calcified Nodules and Cholesterol Crystals After JETSTREAM Atherectomy for Femoropopliteal Lesion, Identified by Pathology and MicroCT.

Atherectomy devices are often utilized to treat heavily calcified peripheral arterial lesions; however, these procedures carry a risk of distal embolization. A 57-year-old patient on hemodialysis underwent JETSTREAM Atherectomy for a heavily calcified superficial femoral artery lesion. Despite successful debulking and drug-coated balloon angioplasty, distal embolization occurred, leading to irreversible toe ischemia and subsequent amputation. Micro-computed tomography and histology of the amputated specimen revealed embolized nodular calcification and cholesterol crystals, confirming plaque-derived debris as the cause. This is the first report to demonstrate such emboli using both modalities. The case underscores the limitations of built-in aspiration and highlights the importance of careful patient selection, procedural planning, and consideration of embolic protection in complex femoropopliteal interventions.