Bookmarks
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
- Typically present for > 3 months
- 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
- Type A: Endovascular procedures recommended
- Unsuccessful attempt at TASC III consensus
- Multiple recommendations in document
- Chronic total occlusion (CTO): Complete arterial blockage (e.g., > 99%); usually due to atherosclerosis
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
- Path of least resistance in CTO compared to chronically occluded true lumen vessel
- 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 space is actually potential space
- 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
- Snared guidewire withdrawn via antegrade sheath
- Retrograde subintimal recanalization then performed from distal puncture access site
- Intraluminal recanalization: Guidewire and catheter combination used to traverse chronically thrombosed/plaque-filled arterial lumen
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
Loading...
Related Differential Diagnoses
Loading...
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
- Typically present for > 3 months
- 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
- Type A: Endovascular procedures recommended
- Unsuccessful attempt at TASC III consensus
- Multiple recommendations in document
- Chronic total occlusion (CTO): Complete arterial blockage (e.g., > 99%); usually due to atherosclerosis
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
- Path of least resistance in CTO compared to chronically occluded true lumen vessel
- 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 space is actually potential space
- 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
- Snared guidewire withdrawn via antegrade sheath
- Retrograde subintimal recanalization then performed from distal puncture access site
- Intraluminal recanalization: Guidewire and catheter combination used to traverse chronically thrombosed/plaque-filled arterial lumen
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
