The MAC score told Mariano everything he needed to know before he touched the wire.
72-year-old, diabetic, Rutherford 6, right foot with gangrene of the first and fifth toes and plantar involvement. Three surgeons had already opened the foot surgically, found nothing usable, and referred for BKA.
Mariano’s team ran a CO2 angiogram, found the plantar circulation was fed by a peroneal posterior branch (anatomical variation nobody had imaged), and then he did something that looks reckless if you don’t understand the logic behind it.
He went subintimal. Aggressively. Recanalized the peroneal in about two minutes with an 0.35 NaviCross and a half-stiff J-tip Terumo wire. Pushed the catheter with the wire rather than just advancing the wire alone. Controlled the loop, used the tip, not the stiff part. Same wire, same technique to navigate the lateral plantar once he entered the foot through the posterior branch.
Why was he comfortable being that aggressive?
Because the MAC score was low.
His line: “No calcium is in high percentage a big synonym of subintimal and fast cross.”
That one sentence reframes the entire decision tree. Low MAC means subintimal dissection is forgiving. You can move fast, you can loop, you can push. High MAC changes everything. You’d need to stay intraluminal because subintimal dissection in heavily calcified tibials is brutal, and in calcified foot arteries it’s close to impossible.
So the calcification score isn’t just a descriptor on the chart. It’s the variable that determines whether you’re doing a two-minute recanalization or a completely different procedure.
And then the part that stuck with me. As Mariano navigated deeper into the foot, he started finding vasculature nobody expected. A hibernated lateral plantar. The arch communicating to dorsal circulation. Fourth and fifth metatarsal arteries lighting up.
Miguel made the point that no pre-operative image would have shown any of this. You don’t get a blueprint before you go in. You get breadcrumbs. Each step of the procedure reveals the next clue, and you follow it.
That’s the part I think most trainees don’t hear enough. The plan isn’t supposed to be perfect before you start. The plan builds itself as you move, if you know what to look for and you have the technical vocabulary to follow where it leads.
Mariano found the distal distribution system, saw the arch connect, and said: “Now I have a lot of hope because I have a distal distribution system, so I know I can make it function.”
Three months later the patient healed. Walking. Limb saved with a transmetatarsal amputation.
The MAC score gave him permission to be aggressive. The technique gave him access. And the willingness to follow breadcrumbs instead of demanding a perfect map gave the patient a foot.
