Crossing Algorithm for Infrainguinal Chronic Total Occlusions: An Interdisciplinary Expert Opinion Statement
- PMID: 36792256
- DOI: 10.1016/j.jcin.2022.11.036
Crossing Algorithm for Infrainguinal Chronic Total Occlusions: An Interdisciplinary Expert Opinion Statement
Abstract
A crossing algorithm was developed for the endovascular treatment of peripheral chronic total occlusive lesions (CTOs) to educate, guide, and appropriately influence clinical practice aiming at harmonization and standardization of endovascular procedures. The following steps are proposed: One, duplex sonography and if required computed tomography or magnetic resonance angiography for the selection of the optimal access site. Two, angiographic evaluation of the proximal/distal cap morphology, presence of collaterals at the origin of the proximal cap and at the distal vessel refilling site. In addition, evaluation of distal vessels, including their diameters and quality, and the presence of calcification or stents within the occlusion zone. Three, antegrade wiring strategies, guidewire (GW) and support catheter technology, as well as GW escalation strategies. Stop the antegrade attempt depending on clinical indication for peripheral artery disease treatment and the presence of retrograde options. Four, retrograde access site, support catheter, or sheath insertion and wiring technology from distally. Five, considering strategy change when progress cannot by achieved, using advanced bidirectional techniques and re-entry devices. Six, in case of successful GW passage from retrograde, GW externalization and treatment from antegrade. Management of the retrograde access by internal or external hemostasis at the end of the procedure. Alternatively, stop the procedure if no progress can be obtained within 3 hours or in case of specific complications. By establishing the algorithm in the daily routine of endovascular specialists, improvements in vessel- and patient-specific outcomes are anticipated. In addition, future research, and continuous collaboration between experts is warranted.
Keywords: antegrade/retrograde crossing; duplex sonography; endovascular repair; guidewires (GWs); infrainguinal; intravascular ultrasound; peripheral chronic total occlusions (CTO); re-entry catheter devices; treatment algorithm.
Copyright © 2023 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.
Conflict of interest statement
Funding Support and Author Disclosures Prof Korosoglou has received speaker honoraria from Philips, Boston Scientific, and Bard Peripheral Vascular Inc.; and institutional grants from Philips and Bard Peripheral Vascular Inc. Dr Schmidt has been a consultant for Abbott, Cook Medical, Reflow Medical, and Upstream Peripheral. Dr Lichtenberg has received honoraria from Abbott Vascular, BD Bard, Medalliance, Biotronik, Boston Scientific Corp., Cook Medical, Medtronic, Philips, Shockwave, Veryan, Limflow, Biotronik, Cordis CSI, Penumbra, and Cardionovum; has consulted for CSI, Gore & Associates, Medtronic, Veryan, Philips-Intact Vascular, Shockwave, Bayer, Vesper Medical, Cagent Vascular, Cordis, Medalliance, Reflow Medical, Bolt Medical; and has received institutional grants for research, clinical trial, or drug studies from Bard Peripheral Vascular, Veryan, Biotronik, Philips, Terumo, Med Alliance, Intact Vascular, Surmodics, Reflow Medical, and Cardionovum. Dr Torsello has received research funding and speaker honoraria from Boston Scientific, WL Gore, Cook, and Medtronic. Dr Grözinger has received speaker honoraria from Abbott, Biotronik, Cordis, and Siemens. Dr Mustapha has been a consultant for Angiodynamics, Avinger, Bard Peripheral Vascular Inc., Cardiovascular Systems Inc., Medtronic, PQ Bypass (Endologix), Philips, and Terumo. Dr Varcoe has received modest consultant fees from Abbott Vascular, Boston Scientific, Philips, W.L. Gore, BD Bard, Medtronic, Nectero, Intervene, and Surmodics. Dr Zeller has received honoraria from Abbott Vascular, Biotronik, Boston Scientific Corp., Cook Medical, Gore & Associates, Medtronic, Philips-Spectranetics, Shockwave, and Veryan; has consulted for Boston Scientific Corp., CSI, Gore & Associates, Medtronic, Veryan, Philips-Intact Vascular, Shockwave, Bayer, Vesper Medical, VentureMed, and ANT; and has received institutional grants for research, clinical trial, or drug studies from Bard Peripheral Vascular, Veryan, Biotronik, Cook Medical, Gore & Associates, Medtronic, Philips, Terumo, TriReme, Shockwave, Med Alliance, Intact Vascular, B. Braun; CSI, Boston Scientific, University of Jena, Pluristem, PQ Bypass, Surmodics, Reflow Medical, and Ablative Solutions. Dr Blessing has received speaker honoraria from Cardinal Health, Abbott Vascular, Philips, Biotronik, Boston Scientific Corp, Medtronic, Terumo, and Shockwave. Dr Langhoff has lectured for and received research grants from B. Braun.
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