Review
Novel devices and specialized techniques in recanalization of peripheral artery chronic total occlusions (CTOs) — A literature review

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Abstract

Currently, recanalization of chronic total occlusions (CTOs) in peripheral arteries remains a challenging obstacle encountered by clinical practitioners. Percutaneous CTO interventions are associated with low rates of procedural success using standard guidewires and catheters. When guidewires cannot cross the occluded segment or fail to reenter the true lumen after subintimal crossing of the occlusion, successful recanalization may be unachievable. In the last few years, the emergence of novel devices and new techniques has dramatically improved the success rates of the revascularization for CTOs. This paper reviews the published data of current devices and specialized techniques of percutaneous intervention to relieve CTOs.

Introduction

Recanalization of chronic total occlusions (CTOs) in peripheral arteries is still technically challenging and time consuming. Prolonged fluoroscopy exposure and higher contrast loads may also be used due to the complex nature of CTOs. Most patients with peripheral artery CTOs suffer from critical limb ischemia or disabling claudication [1]. The conventional technique using standard guidewires and catheters can achieve an initial success in about 40%–60% of cases [2], depending on lesion characteristics (length, location, calcification and runoff vessel status) and operator's experience. The subintimal angioplasty of CTOs first described by Bolia et al. [3] is widely used nowadays, which can achieve success rates of 74%–92% [4], [5], [6]. However, the acute failure of endovascular treatment of CTOs is most often due to an inability to pass through the calcified true lumen or to reenter the true lumen after subintimal crossing of the occluded segment. Multiple novel devices and techniques have emerged in the past years for the revascularization of CTOs.

Section snippets

Novel assist devices to cross the occluded leisons

Revascularization of CTOs can be hampered when the guidewire fails to cross the occluded lesion. For this reason, several devices are designed to facilitate guidewire crossing the occluded lesion into the distal true lumen, by which subsequent and more definitive therapies such as atherectomy, balloon angioplasty, and stent implantation are achievable. The blunt microdissection device (Frontrunner catheter) and high-frequency vibrational energy device (Crosser catheter) are both available in

True lumen reentry devices

Over the last two decades subintimal angioplasty (SIA) has been successfully utilized for recanalization of selected patients suffering from CTOs in peripheral artery disease which was initially described by Bolia et al. [3]. The key of the successful SIA is the capability to regain access to the true lumen from the subintimal plane at a suitable site. SIA using hydrophilic guidewires and a support catheter alone can achieve 80% procedural success [17], however, in 20% of the patients, true

Specialized techniques

In most cases endovascular revascularization of CTOs can be achieved crossing the lesion endoluminally or subintimally from either a contralateral retrograde or an ipsilateral antegrade approach. Whereas the proximal stump of a chronic occlusion frequently consists of a hard “cap” (fibrous atherosclerotic plaque), the distal “cap” of the occluded lesion may be softer than the proximal aspect and may be easier to penetrate with a guidewire. In the subset of patients in whom ipsilateral antegrade

Summary

Recanalization of CTOs is posing a big challenge in achieving acute treatment success by its complex nature. Novel devices and special techniques have facilitated the procedure and with this increased the acute success rate. Moreover, treatment time and contrast medium loads are reduced, especially in long complex lesions. However, there is no first recommendation for the choice of the devices and techniques. It depends on the lesions' nature, the physicians experience and the conditions of

Acknowledgments

We sincerely thank Prof. Thomas Zeller for critical revision of this article. The authors of this manuscript have certified that they comply with the Principles of Ethical Publishing in the International Journal of Cardiology.

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