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Chronic Total Occlusion Revascularization
T. Gregory Walker, MD, FSIR
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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
              • Lesion location (e.g., aortoiliac/femoropopliteal)
              • Lesion type (stenosis vs. occlusion)
              • Lesion length/disease severity in runoff arteries
            • TASC II categories
              • Type A: Endovascular procedures recommended
                • Should be 1st-line treatment
              • Type B: Endovascular procedures recommended
                • 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

                            1. 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
                            2. 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
                            3. 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
                            4. Bague N et al: The role for DCBs in the treatment of ISR. J Cardiovasc Surg (Torino). 57(4):578-85, 2016
                            5. 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
                            6. 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
                            7. 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
                            8. 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
                            9. Bausback Y et al: Outback catheter for femoropopliteal occlusions: immediate and long-term results. J Endovasc Ther. 18(1):13-21, 2011
                            10. 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
                            11. 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
                            12. 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
                            13. Gandini R et al: The "Safari" technique to perform difficult subintimal infragenicular vessels. Cardiovasc Intervent Radiol. 30(3):469-73, 2007
                            14. 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
                            15. 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
                                        • Lesion location (e.g., aortoiliac/femoropopliteal)
                                        • Lesion type (stenosis vs. occlusion)
                                        • Lesion length/disease severity in runoff arteries
                                      • TASC II categories
                                        • Type A: Endovascular procedures recommended
                                          • Should be 1st-line treatment
                                        • Type B: Endovascular procedures recommended
                                          • 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

                                                      1. 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
                                                      2. 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
                                                      3. 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
                                                      4. Bague N et al: The role for DCBs in the treatment of ISR. J Cardiovasc Surg (Torino). 57(4):578-85, 2016
                                                      5. 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
                                                      6. 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
                                                      7. 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
                                                      8. 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
                                                      9. Bausback Y et al: Outback catheter for femoropopliteal occlusions: immediate and long-term results. J Endovasc Ther. 18(1):13-21, 2011
                                                      10. 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
                                                      11. 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
                                                      12. 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
                                                      13. Gandini R et al: The "Safari" technique to perform difficult subintimal infragenicular vessels. Cardiovasc Intervent Radiol. 30(3):469-73, 2007
                                                      14. 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
                                                      15. Bolia A et al: Recanalisation of femoro-popliteal occlusions: improving success rate by subintimal recanalisation. Clin Radiol. 40(3):325, 1989