Review
doi: 10.1055/s-0038-1676343.
Epub 2019 Feb 5.
Long Chronic Total Occlusions: Revascularization Strategies
Affiliations
- PMID: 30728663
- PMCID: PMC6363540
- DOI: 10.1055/s-0038-1676343
Item in Clipboard
Review
Long Chronic Total Occlusions: Revascularization Strategies
Semin Intervent Radiol.
2018 Dec.
Abstract
The treatment of chronic total occlusions (CTO) in patients with peripheral arterial disease (PAD) is a complex topic with multiple treatment techniques and treatment strategies. The interventionalist treating patients with PAD should have both a defined treatment algorithm and multiple techniques available for crossing these challenging lesions. This article will cover techniques for treating CTOs and provide an overview of current available evidence.
Keywords: angioplasty; chronic total occlusion; interventional radiology; peripheral arterial disease; recanalization; stent.
Figures
A 64-year-old woman (Rutherford 4). Initial arteriography (
a
) demonstrates long-segment occlusion through the SFA (
arrow
) with reconstitution at the adductor canal (
arrowhead
). An Outback reentry device was advanced over a 0.014-in Spartacore wire (
b
). The device was oriented to direct the sharp cannula medially toward the atherosclerotic calcifications (
arrow
). After PTA through the SFA, residual narrowing of >30% was identified (
c
,
arrow
). Drug-eluting stents were placed through the SFA with good angiographic result (
d and e
). PTA, percutaneous transluminal angioplasty; SFA, superficial femoral artery.
A 72-year-old man (Rutherford 5). Initial arteriography (
a
) demonstrates long-segment occlusion of the SFA with previously placed stents (
arrow
) and occluded bypass (
arrowhead
). Initial arteriography at the level of the knee (
b
) shows reconstitution of the proximal AT. After failed antegrade attempt (
c
,
arrowhead
), retrograde access was achieved in the anterior tibial (AT) artery and advanced to the AT origin (
arrow
). The antegrade and retrograde access would not communicate in the subintimal space of the SFA and the retrograde access was advanced to the CFA (
d
,
arrow
). A snare was advanced through the antegrade access and used to externalize the retrograde wire (
E
,
arrow
). Post–stent placement arteriographs (
f and g
) show in-line flow through the SFA to the AT. CFA, common femoral artery; SFA, superficial femoral artery.
A 79-year-old woman (Rutherford 4). Initial arteriography (
a
) demonstrates long-segment occlusion through the SFA (
arrow
) with possible reconstitution at the adductor canal (
arrowhead
). A subintimal plane was started for revascularization (
b
,
arrow
). An attempt at reentry was performed with the Outback device (
c
,
arrow
). After achieving retrograde access through the AT, the retrograde wire was advanced through the antegrade access catheter within the subintimal plane (
d
,
arrow
). Post–stent placement arteriographs show patent SFA with in-line flow (
e
and
f
). SFA, superficial femoral artery.
Algorithm for endovascular CTO strategies. CTO, chronic total occlusion; PTA, percutaneous transluminal angioplasty.
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