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Background  Leriche syndrome is the result of the atherosclerotic occlusion of the distal aorta that may also involve pelvic arteries. The standard treatment for this condition is considered surgical with various techniques available for establishing appropriate flow to both limbs. However, due to the technical advances in the last decades, endovascular approaches are now also capable to tackle such lesions. The ‘pave-and-crack’ technique enables the treatment of severely calcified lesions. This two-step procedure consists of firstly placing a covered stent prothesis (VIABAHN) into the severely calcified segment, which is afterwards aggressively dilated with high-pressure balloons. Subsequently, an interwoven nitinol SUPERA stent with high radial forces is placed within the prothesis. Case summary  Herein, we describe the case of an 81-year-old male patient, who presented with critical limb-threatening ischaemia of his right leg. Doppler ultrasound revealed a long occlusion of the right external iliac artery, common femoral, superficial femoral, and deep femoral artery. The lesion was successfully tackled using antegrade and retrograde punctures and the ‘pave-and-crack’ technique. Discussion  The ‘pave-and-crack’ technique is an endovascular approach for the treatment of severe circumferential calcified lesions. Based on this technique covered stents are initially placed to prevent vessel rupture, which might occur during the aggressive balloon dilatation. Subsequently, the covered stents are relined by interwoven Supera stents, which provide high radial force preventing recoil and restenosis.

european heart journal. case reports

‘Pave-and-crack’ technique for the recanalization of severely calcified occlusive aorto-ilio-femoral disease in type-III Leriche syndrome: a case report