Endovascular Approach to CTOs: Crossing methods and Devices
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1 Endovascular Approach to CTOs: Crossing methods and Devices Anish J. Thomas, MD FACC FSCAI Interventional Cardiology Vascular/Endovascular Medicine SSM Heart Institute St. Louis, MO
2 Disclosure Consultant: Abbott Vascular CSI
3 Approach Access Femoral, Radial, Brachial, Popliteal, Tibio-pedal Angiography CTA, pre-procedure angiography Crossing Treatment Anticipate potential complications
4 Aorto-Iliac occlusions
5 Access Key to success Often will need multiple points of access Femoral Brachial/Radial US guided access: Learn how to do it Access using road map
6 Angiography Multiple views CTO proximal cap: Beaked, Flush occlusion, collateral (s) coming off Lesion morphology Reconstitution point Treatment from an antegrade or retrograde access
7 Crossing Adequate Sheath/Guide support Most of the time it is easier to cross iliac occlusion from above, however not always the case Glide wires and support catheter If you see a micro channel 0.014/0.018 wires have better torque May need to use a re-entry device: Outback, Pioneer
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9 Case: EIA Occlusion
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12 Case: CIA Occlusion
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14
15
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17 Distal Aortic Occlusion
18 Fem-Popliteal occlusions
19 Access Contra-lateral CFA access Ipsilateral Antegrade CFA access Retrograde: Popliteal/Distal SFA/Tibio-pedal access Failure to cross from an antegrade access
20 Angiography Angulated views True Flush SFA occlusion Calcification Look at the contralateral side: Frequently symmetrical bifurcation Evaluate morphology Runoff Reconstitution Use of re-entry device for failed antegrade cross Evaluate need for retrograde access
21 Crossing Wire based technique 0.035, 0.018, Support catheters Use of re-entry catheters if unable to get into the true lumen at the distal reconstitution Retrograde access/crossing
22 Crossing Devices AVINGER Wildcat, Ocelot CROSSER LASER: Step by Step TruePath Viance
23 Case 1
24
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26 Post Directional Atherectomy and DCB angioplasty
27 Case 2
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29
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31 Post Stenting with overlapped 5.5 x150 mm, 6.5x150/2 mm Nitinol interwoven stents
32 Case 3 Attempted to cross with a CTO device, but subintimal at point of reconstitution Attempts to reenter with an angled support catheter and tapered wire unsuccessful Successful Re-entry using an Outback reentry device PTA and stenting with Nitinol interwoven stent
33 Case 4 Dense calcified proximal popliteal CTO Numerous collateral coming off the proximal cap (No definite beak) Reconstitution at the Proximal AT and mid to distal Posterior tibial
34 Inability to penetrate proximal cap given numerous collaterals coming off Retrograde US guided distal AT access, angled support catheter Retrograde subintimal crossing of dense P2 segment CTO Retrograde wire advanced, entered true lumen and externalized
35 Adequate angioplasty of the proximal and mid Popliteal artery Stenting of the distal SFA to mid popliteal with Nitinol interwoven stents Angioplasty of the distal popliteal into the anterior tibial with a DCB
36 Anticipate Complications Perforations Recognize thrombotic occlusions Distal embolization. Use EP if you think you need it
37 Summary Study the angiograms Have a plan Plan B, Plan C Know what equipment you have on shelf Know your limitations
38 Endovascular Approach to CTOs: Crossing methods and Devices Anish J. Thomas, MD FACC FSCAI Interventional Cardiology Vascular/Endovascular Medicine SSM Heart Institute St. Louis, MO
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