Arterial Interventions and Peripheral Arterial Disease (PAD)

Session: Educational Exhibit Presentations - Station 1: Arterial Interventions and Peripheral Arterial Disease (PAD)

A Review of Techniques to Cross Lower Extremity Chronic Thrombotic Occlusions

Monday, March 6, 2023

5:45 PM – 5:50 PM

Location: Phoenix Convention Center, North Ballroom 120ABC, Poster Hall

Abstract Presenter(s)

Lucas Betts

Medical Student
Creighton University

Disclosure(s): No financial relationships to disclose

Author/Co-author(s)

DK

Deepak Kesani, DO

Radiology Resident R3
Sunrise GME Consortium
SM

Steve Mathew, MD

Radiology Resident R3
Creighton University

Disclosure(s):

Lucas Betts: No financial relationships to disclose

Steve Mathew, MD: No financial relationships to disclose

Learning Objectives: 1. Understand various Chronic Thrombotic Occlusion (CTO) morphology and its relevance to intervention.
2. Elaborate on a few CTO crossing algorithms, and how/whether they are relevant for intervention.
3. Explain various antegrade and retrograde CTO crossing techniques and available hardware.

Background: Peripheral arterial disease (PAD) is currently an epidemic in the US particularly with the older age, and comorbidities such as diabetes mellitus. Currently, surgeons and cardiologists are the leading providers of vascular intervention for PAD (1). Given the origin of PAD intervention within the field of IR, it is vital to keep up to date with new techniques and hardware for peripheral arterial intervention. Chronic thrombotic occlusions (CTO) are highly prevalent in the PAD, and the techniques below can assist with crossing the lesion, allowing increased blood supply and saving limbs.

Clinical Findings/Procedure Details: Endovascular crossing of CTO's are vitally important in PAD, particularly in patients with severe disease when they have critical limb ischemia. Intervention can prevent surgical amputations, and improve wound healing in patients with wounds related to arterial ulcers or diabetes. Strategies for lesion crossing can possibly be made more algorithmic based on plaque morphology (2). The importance of CTO plaque morphology, and how it allows for easier retrograde vs antegrade intervention, and intimal vs subintimal recanalization will be discussed. There are currently a few available CTO intervention algorithms such as those by Roy, and Banerjee that will be discussed (3, 4). However, their use has not been extensively validated and criticisms and controversies will be addressed. Most importantly, the varying techniques for CTO crossing will be discussed using cases including sliding, drilling, drilling via specialized hardware, parallel wire, subintimal recanalization, ablation of plaque, CART, reverse CART, SAFARI and various flossing based techniques will be discussed.

Conclusion and/or Teaching Points: After the presentation, learners will be able to describe the common algorithms for approaching CTOs, and describe the numerous available techniques and common hardware. This should help to serve as an introduction to further practicing such techniques under supervision.