Crossing Chronic Total Occlusions of the Iliac and Femoral-Popliteal Vessels and the Use of True Lumen Reentry Devices

Subintimal revascularization is a mainstay of therapy for lower extremity interventions. This stems from the realization that true lumen traversal is not always possible, subintimal revascularization has a high technical success rate, and the subintimal space may confer advantages over a heavily calcified true lumen. Most commonly in the tibial vasculature, there are times when subintimal recanalization is not possible because the wire and catheter may leave the subintimal plane and enter the periadventitial tissue. Although this is not intentional, exit from the vessel historically results in a technical failure because future passes of the wire and catheter are likely to follow suit, as evidenced by extravasation on contrast injection. This chapter describes two techniques to salvage this scenario and accept an extravascular tract for revascularization: the Outback® extravascular revascularization technique and the percutaneous gun-sight extravascular revascularization technique.

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Balloon Occlusion of Subintimal Tract to Assist Distal Luminal Re-entry During Subintimal Recanalization of Chronic Total Occlusions

10.1093/med/9780199986071.003.0017 ◽

2018 ◽

Author(s):

Abdel Aziz A. Jaffan

Keyword(s):

Failure Rate ◽

Peripheral Circulation ◽

Balloon Occlusion ◽

Technical Failure ◽

True Lumen ◽

Chronic Total Occlusions ◽

Femoropopliteal Artery ◽

Endovascular Recanalization ◽

Difficult Cases ◽

Established Technique

The balloon occlusion of subintimal tract (BOST) technique may be used to assist in regaining luminal re-entry in difficult cases during subintimal recanalization of chronic total occlusions in the femoropopliteal artery. Subintimal recanalization or percutaneous intentional extraluminal recanalization (PIER) is an established technique used in endovascular recanalization of chronically occluded arteries of the peripheral circulation. The primary limitation of PIER is the high technical failure rate. Failure is mainly due to the inability to re-enter the patent true lumen distal to the site of the occlusion. The BOST technique can help overcome this limitation. This chapter provides a description of the technique.

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A new technique in complex chronic total occlusions: puncture through a subintimally placed microsnare with a reentry device from the true lumen to achieve through and through antegrade-retrograde access

Journal of Vascular and Interventional Radiology ◽

10.1016/j.jvir.2013.12.265 ◽

2014 ◽

Vol 25 (3) ◽

pp. S94

Author(s):

B. Arslan ◽

J.C. Tasse ◽

K. Wepking ◽

U. Turba

Keyword(s):

New Technique ◽

True Lumen ◽

Chronic Total Occlusions ◽

A New Technique

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Parallel Wiring Using a Single Intravascular Ultrasound Catheter with Double Rapid Exchange Lumens Technique for Chronic Total Occlusions in Peripheral Artery Disease

Journal of Endovascular Therapy ◽

10.1177/15266028211036483 ◽

2021 ◽

pp. 152660282110364

Author(s):

Michinao Tan ◽

Kazushi Urasawa ◽

Yusuke Sato ◽

Takashi Miwa ◽

Taichi Hayashi

Keyword(s):

Intravascular Ultrasound ◽

Peripheral Artery Disease ◽

Popliteal Artery ◽

Peripheral Artery ◽

True Lumen ◽

Chronic Total Occlusions ◽

Novel Technique ◽

Rapid Exchange ◽

Exit Port ◽

Artery Disease

Purpose: To describe a parallel wiring using a single intravascular ultrasound catheter with double rapid exchange lumens (PASSABLE) technique for peripheral CTOs. Technique: The technique is demonstrated in a 73-year-old patient with CTOs of the superficial femoral and popliteal artery. Intravascular ultrasound (IVUS) examination revealed the first guidewire was advanced to the intramedial space of the popliteal artery. Following insertion of the first guidewire into only the distal rapid exchange lumen of the IVUS catheter and a second guidewire into the proximal rapid exchange lumen, a guidewire torquer was passed over it and tightened close to an exit port of the proximal rapid exchange lumen to prevent it from exiting an entry port while advancing the IVUS catheter. The IVUS catheter was advanced to the intraplaque region using only the distal rapid exchange lumen and the second guidewire was then advanced to the intraplaque region under IVUS guidance. The IVUS-guided wiring using the second guidewire on both the distal and proximal rapid exchange lumen was continued and resulted in a successful guidewire crossing into the distal true lumen. Conclusion: This novel technique may prove beneficial in enabling operators to perform IVUS-guided parallel wiring more easily and efficiently.

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TCTAP A-107 Safety and Efficacy of True Lumen Tracking Recanalization for the Chronic Total Occlusions of Iliac and Femoral Artery

Journal of the American College of Cardiology ◽

10.1016/j.jacc.2014.02.127 ◽

2014 ◽

Vol 63 (12) ◽

pp. S30

Author(s):

Rie Sugawara ◽

Ren Kawaguchi ◽

Yusuke Miyaishi ◽

Hakuken Kan ◽

Hiroshi Hoshizaki ◽

...

Keyword(s):

Femoral Artery ◽

True Lumen ◽

Safety And Efficacy ◽

Chronic Total Occlusions

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Tools of the Trade: Adjunctive Tools for Lesion Crossing in Critical Limb Ischemia

Medical Equipment Insights ◽

10.4137/mei.s18479 ◽

2015 ◽

Vol 6 ◽

pp. MEI.S18479 ◽

Cited By ~ 1

Author(s):

Andrew M. Goldsweig ◽

Faisal Hasan ◽

Carlos Mena

Keyword(s):

Ultraviolet Light ◽

Critical Limb Ischemia ◽

Tissue Damage ◽

Limb Ischemia ◽

True Lumen ◽

Chronic Total Occlusions ◽

Vessel Lumen ◽

Distal Vessel ◽

Laser Atherectomy

Critical limb ischemia (CLI) due to obstructive atherosclerosis causes pain and tissue damage and may result in amputation and death. Revascularization saves the limbs and lives of patients with CLI. This review addresses adjunctive tools for lesion crossing, including mechanical atherectomy, laser atherectomy, crossing devices, and luminal reentry devices. Mechanical atherectomy devices are designed to excise atheroma, often heavily calcified, thereby preparing a channel for further intervention. Mechanisms (and devices) include directional (SilverHawk™, TurboHawk™, RockHawk™), rotational (Jetstream™, Pheonix™), and orbital (Diamondback 360°™, Predator 360°™, Stealth 360°™) atherectomy. A laser atherectomy device (Turbo Elite™) vaporizes atheroma by heating tissues with ultraviolet light. Crossing devices specifically designed for chronic total occlusions either navigate a vessel's true lumen or guide a controlled subintimal course with reentry into the distal true lumen. Crossing devices include Crosser® Catheter, Wildcat™, Ocelot™, Kittycat™, TruePath™, Viance™, Frontrunner™, TOTAL across™, and PowerWire™. When a guidewire or crossing device traverses a lesion via a subintimal course, a luminal reentry device may facilitate deployment of the guidewire in the distal vessel lumen. Reentry devices include Outback LTD™, Offroad™, Pioneer Plus™, and Enteer™.

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IVUS Assessment of the Crossing Pathway of an Intraluminal Reentry Device Used in the Primary Treatment of Infrainguinal Chronic Total Occlusions

Journal of Endovascular Therapy ◽

10.1177/1526602819884054 ◽

2019 ◽

Vol 27 (1) ◽

pp. 69-76 ◽

Cited By ~ 1

Author(s):

Yusuke Tomoi ◽

Mitsuyoshi Takahara ◽

Masahiko Fujihara ◽

Masashi Fukunaga ◽

Yusuke Iwasaki ◽

...

Keyword(s):

Outcome Measures ◽

Significant Risk ◽

Significant Risk Factor ◽

Primary Treatment ◽

True Lumen ◽

Chronic Total Occlusions ◽

Antegrade Approach ◽

History Of ◽

Patient Variables ◽

Device Use

Purpose: To examine with intravascular ultrasound (IVUS) the crossing pathways of the TruePath reentry device during primary antegrade recanalization of infrainguinal chronic total occlusions (CTOs). Methods: Between July 2017 and September 2018, a prospective multicenter study enrolled 143 consecutive patients (mean age 75±9 years; 101 men) with 146 CTOs treated in an antegrade approach using the TruePath reentry device with IVUS assessment of the crossing pathway in successful cases. Outcome measures were complete success (reentry device reached the distal true lumen), assisted success (reentry device use followed by a conventional guidewire to reach the distal true lumen), reentry device crossing route by IVUS assessment, and procedure- and device-related complications. Regression analyses were employed to identify any relevant associations between baseline patient variables and the outcome measures; results are presented as the odds ratio (ORs) and 95% confidence interval (CI). Results: Complete success was achieved in 82 (56.2%) lesions; any success (complete plus assisted) was documented in 117 (80.1%) lesions. Four (3%) perioperative device-related complications were observed. The crossing route was intraplaque for most of the total crossing distance in both complete success cases (95.3%±13.2%) and any success cases (94.8%±14.4%), with relatively short subintimal (3.6%±10.2% and 4.2%±11.2%, respectively) or intramedial (1.2%±5.8% and 1.0%±5.4%, respectively) crossing. CTO length was a significant risk factor for not achieving complete success (OR 1.74, 95% CI 1.13 to 2.68, p=0.012), and a history of failed revascularization was associated with not achieving any success (OR 6.40, 95% CI 1.28 to 28.9, p=0.038). Conclusion: The intraplaque route was the primary pathway taken by the TruePath reentry device as it crossed infrainguinal CTOs. Crossing rates were acceptable, with few device-related complications. However, a longer CTO length and a failed revascularization history negatively affected the success rate.

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Advances in percutaneous coronary intervention for chronic total occlusions: current antegrade dissection and reentry techniques and updated algorithm

Netherlands Heart Journal ◽

10.1007/s12471-020-01509-8 ◽

2020 ◽

Vol 29 (1) ◽

pp. 52-59 ◽

Cited By ~ 1

Author(s):

T. Berkhout ◽

B. E. Claessen ◽

M. T. Dirksen

Keyword(s):

Percutaneous Coronary Intervention ◽

Coronary Artery ◽

Hybrid Algorithm ◽

Coronary Intervention ◽

Complication Rates ◽

Success Rates ◽

New Materials ◽

True Lumen ◽

Chronic Total Occlusions ◽

Percutaneous Coronary

AbstractPercutaneous coronary intervention (PCI) for chronic total occlusions (CTO) is considered relatively complex with low success rates and high complication rates. Treating a CTO with PCI using the hybrid algorithm increases success rates with acceptable complication rates. An essential part of the hybrid algorithm is antegrade dissection and reentry (ADR). In PCI of a non-CTO coronary lesion, the guidewire over which the stent is advanced and placed stays within the true lumen of the coronary artery. ADR techniques make it possible to cross the lesion through the wall of the coronary artery, the subintimal space, thus creating a small bypass within the architecture of the coronary artery and restoring antegrade blood flow. ADR increases success rates, especially in more difficult CTO procedures. In the last decade, new materials and techniques have been introduced in quick succession, which are summarised in this review. Consequently an updated ADR algorithm is presented, which can support the CTO operator during an ADR procedure.

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