Unless surgery required for other lesions located in same anatomic area
Type C: Open revascularization recommended
Endovascular procedures recommended only if potential for poor healing after open surgery
Type D: Endovascular procedures not recommended as 1st-line treatment
Unsuccessful attempt at TASC III consensus
CTO Revascularization Techniques
Intraluminal recanalization: Guidewire and catheter combination used to traverse chronically thrombosed/plaque-filled arterial lumen
Must initially penetrate proximal edge of CTO
Guidewire/catheter then used to negotiate entire length of CTO while remaining intraluminal
Must enter reconstituted patent lumen below CTO
Subintimal recanalization: Intentional extraluminal passage of guidewire/catheter in subintimal space during attempted CTO revascularization
Subintimal space is actually potential space
Path of least resistance in CTO compared to chronically occluded true lumen vessel
Allows fairly easy guidewire/catheter passage
Requires guidewire/catheter reentry into reconstituted distal arterial segment
Failure to reenter true lumen after subintimally crossing CTO is primary limitation to success
Failure to achieve reentry until quite distal to point of arterial reconstitution may put additional branch points/collaterals at risk
If subintimal angioplasty/stenting extends excessively beyond occluded segment
May put potential "no-stent zones" (e.g., common femoral/popliteal arteries) at risk
Subintimal recanalization with sharp reentry: Specialized reentry catheter used to gain access into distal arterial segment after subintimal recanalization
Standard subintimal recanalization performed
Catheter fails to reenter distal arterial segment
Catheter removed, leaving guidewire subintimal
Reentry catheter advanced over guidewire
Small, directionally controlled, hollow needle near catheter tip used to pierce intima into true lumen
Microwire introduced via needle into true lumen
Device removed, leaving microwire in place to allow catheter placement across CTO
Subintimal arterial flossing with antegrade-retrograde intervention (SAFARI) technique: Retrograde puncture of reconstituted target artery after unsuccessful attempted antegrade recanalization
Retrograde subintimal recanalization then performed from distal puncture access site
Guidewire/catheter passed retrograde though CTO
Guidewire must enter subintimal space/vessel lumen where antegrade catheter located
Retrograde guidewire snared via antegrade catheter
Snared guidewire withdrawn via antegrade sheath
Creates "flossing" guidewire, permitting placement of catheter/PTA balloon across CTO
PREPROCEDURE
Indications
Contraindications
Getting Started
PROCEDURE
Patient Position/Location
Equipment Preparation
Procedure Steps
Alternative Procedures/Therapies
POST PROCEDURE
Things to Do
OUTCOMES
Complications
Expected Outcomes
Selected References
Tajti P et al: Procedural outcomes of percutaneous coronary interventions for chronic total occlusions via the radial approach: insights from an international chronic total occlusion registry. JACC Cardiovasc Interv. 12(4):346-58, 2019
Cioppa A et al: Combined use of directional atherectomy and drug-coated balloon for the endovascular treatment of common femoral artery disease: immediate and one-year outcomes. EuroIntervention. 12(14):1789-94, 2017
Foley TR et al: Mid-term outcomes of orbital atherectomy combined with drug-coated balloon angioplasty for treatment of femoropopliteal disease. Catheter Cardiovasc Interv. 89(6):1078-85, 2017
Bague N et al: The role for DCBs in the treatment of ISR. J Cardiovasc Surg (Torino). 57(4):578-85, 2016
Kitrou P et al: Drug-coated balloons are replacing the need for nitinol stents in the superficial femoral artery. J Cardiovasc Surg (Torino). 57(4):569-77, 2016
Madassery S et al: Role of stent grafts and helical-woven bare-metal stents in the superficial femoral and popliteal arteries. Tech Vasc Interv Radiol. 19(2):153-62, 2016
Lee MS et al: Comparison of diabetic and non-diabetic patients undergoing endovascular revascularization for peripheral arterial disease. J Invasive Cardiol. 27(3):167-71, 2015
Wosik J et al: Systematic review of the BridgePoint system for crossing coronary and peripheral chronic total occlusions. J Invasive Cardiol. 27(6):269-76, 2015
Bausback Y et al: Outback catheter for femoropopliteal occlusions: immediate and long-term results. J Endovasc Ther. 18(1):13-21, 2011
Fanelli F et al: Retrograde popliteal access in the supine patient for recanalization of the superficial femoral artery: initial results. J Endovasc Ther. 18(4):503-9, 2011
Pappy R et al: Retrograde access via the popliteal artery to facilitate the re-entry technique for recalcitrant superficial femoral artery chronic total occlusions. Catheter Cardiovasc Interv. 78(4):625-31, 2011
Schneider JR et al: Results with Viabahn-assisted subintimal recanalization for TASC C and TASC D superficial femoral artery occlusive disease. Vasc Endovascular Surg. 45(5):391-7, 2011
Gandini R et al: The "Safari" technique to perform difficult subintimal infragenicular vessels. Cardiovasc Intervent Radiol. 30(3):469-73, 2007
Spinosa DJ et al: Subintimal arterial flossing with antegrade-retrograde intervention (SAFARI) for subintimal recanalization to treat chronic critical limb ischemia. J Vasc Interv Radiol. 16(1):37-44, 2005
Bolia A et al: Recanalisation of femoro-popliteal occlusions: improving success rate by subintimal recanalisation. Clin Radiol. 40(3):325, 1989
Related Anatomy
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Related Differential Diagnoses
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References
Tables
Tables
KEY FACTS
Terminology
Procedure
Post Procedure
TERMINOLOGY
Definitions
Chronic total occlusion (CTO): Complete arterial blockage (e.g., > 99%); usually due to atherosclerosis
Typically present for > 3 months
Characterized by fibrous cap; varying degrees of hard and soft plaque
In peripheral artery disease (PAD), occlusion predominates over stenosis
Predominance due to limited collaterals
Chronic total venous occlusion: Complete venous blockage; usually due to chronic thrombosis
Characterized by fibrosis; numerous collaterals
Trans-Atlantic Inter-Society Consensus II (TASC II): Comprehensive document for PAD management
Multiple recommendations in document
Risk factor modification
Evaluation strategies
Medical/surgical/endovascular management of
Intermittent claudication
Critical limb ischemia
Acute limb ischemia
Lesions categorized with recommendations for endovascular vs. surgical treatment based on
Unless surgery required for other lesions located in same anatomic area
Type C: Open revascularization recommended
Endovascular procedures recommended only if potential for poor healing after open surgery
Type D: Endovascular procedures not recommended as 1st-line treatment
Unsuccessful attempt at TASC III consensus
CTO Revascularization Techniques
Intraluminal recanalization: Guidewire and catheter combination used to traverse chronically thrombosed/plaque-filled arterial lumen
Must initially penetrate proximal edge of CTO
Guidewire/catheter then used to negotiate entire length of CTO while remaining intraluminal
Must enter reconstituted patent lumen below CTO
Subintimal recanalization: Intentional extraluminal passage of guidewire/catheter in subintimal space during attempted CTO revascularization
Subintimal space is actually potential space
Path of least resistance in CTO compared to chronically occluded true lumen vessel
Allows fairly easy guidewire/catheter passage
Requires guidewire/catheter reentry into reconstituted distal arterial segment
Failure to reenter true lumen after subintimally crossing CTO is primary limitation to success
Failure to achieve reentry until quite distal to point of arterial reconstitution may put additional branch points/collaterals at risk
If subintimal angioplasty/stenting extends excessively beyond occluded segment
May put potential "no-stent zones" (e.g., common femoral/popliteal arteries) at risk
Subintimal recanalization with sharp reentry: Specialized reentry catheter used to gain access into distal arterial segment after subintimal recanalization
Standard subintimal recanalization performed
Catheter fails to reenter distal arterial segment
Catheter removed, leaving guidewire subintimal
Reentry catheter advanced over guidewire
Small, directionally controlled, hollow needle near catheter tip used to pierce intima into true lumen
Microwire introduced via needle into true lumen
Device removed, leaving microwire in place to allow catheter placement across CTO
Subintimal arterial flossing with antegrade-retrograde intervention (SAFARI) technique: Retrograde puncture of reconstituted target artery after unsuccessful attempted antegrade recanalization
Retrograde subintimal recanalization then performed from distal puncture access site
Guidewire/catheter passed retrograde though CTO
Guidewire must enter subintimal space/vessel lumen where antegrade catheter located
Retrograde guidewire snared via antegrade catheter
Snared guidewire withdrawn via antegrade sheath
Creates "flossing" guidewire, permitting placement of catheter/PTA balloon across CTO
PREPROCEDURE
Indications
Contraindications
Getting Started
PROCEDURE
Patient Position/Location
Equipment Preparation
Procedure Steps
Alternative Procedures/Therapies
POST PROCEDURE
Things to Do
OUTCOMES
Complications
Expected Outcomes
Selected References
Tajti P et al: Procedural outcomes of percutaneous coronary interventions for chronic total occlusions via the radial approach: insights from an international chronic total occlusion registry. JACC Cardiovasc Interv. 12(4):346-58, 2019
Cioppa A et al: Combined use of directional atherectomy and drug-coated balloon for the endovascular treatment of common femoral artery disease: immediate and one-year outcomes. EuroIntervention. 12(14):1789-94, 2017
Foley TR et al: Mid-term outcomes of orbital atherectomy combined with drug-coated balloon angioplasty for treatment of femoropopliteal disease. Catheter Cardiovasc Interv. 89(6):1078-85, 2017
Bague N et al: The role for DCBs in the treatment of ISR. J Cardiovasc Surg (Torino). 57(4):578-85, 2016
Kitrou P et al: Drug-coated balloons are replacing the need for nitinol stents in the superficial femoral artery. J Cardiovasc Surg (Torino). 57(4):569-77, 2016
Madassery S et al: Role of stent grafts and helical-woven bare-metal stents in the superficial femoral and popliteal arteries. Tech Vasc Interv Radiol. 19(2):153-62, 2016
Lee MS et al: Comparison of diabetic and non-diabetic patients undergoing endovascular revascularization for peripheral arterial disease. J Invasive Cardiol. 27(3):167-71, 2015
Wosik J et al: Systematic review of the BridgePoint system for crossing coronary and peripheral chronic total occlusions. J Invasive Cardiol. 27(6):269-76, 2015
Bausback Y et al: Outback catheter for femoropopliteal occlusions: immediate and long-term results. J Endovasc Ther. 18(1):13-21, 2011
Fanelli F et al: Retrograde popliteal access in the supine patient for recanalization of the superficial femoral artery: initial results. J Endovasc Ther. 18(4):503-9, 2011
Pappy R et al: Retrograde access via the popliteal artery to facilitate the re-entry technique for recalcitrant superficial femoral artery chronic total occlusions. Catheter Cardiovasc Interv. 78(4):625-31, 2011
Schneider JR et al: Results with Viabahn-assisted subintimal recanalization for TASC C and TASC D superficial femoral artery occlusive disease. Vasc Endovascular Surg. 45(5):391-7, 2011
Gandini R et al: The "Safari" technique to perform difficult subintimal infragenicular vessels. Cardiovasc Intervent Radiol. 30(3):469-73, 2007
Spinosa DJ et al: Subintimal arterial flossing with antegrade-retrograde intervention (SAFARI) for subintimal recanalization to treat chronic critical limb ischemia. J Vasc Interv Radiol. 16(1):37-44, 2005
Bolia A et al: Recanalisation of femoro-popliteal occlusions: improving success rate by subintimal recanalisation. Clin Radiol. 40(3):325, 1989
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