Lower Extremity Non-guide Wire Crossing of Arterial Chronic Total Occlusions

Abstract

Typically, long SFA occlusions crossed with a hydrophilic 0.035″ wire have traversed via the subintimal space. I will review non-guide wire-based therapies in an attempt to cross via the true lumen.

First will be the Spectranetics excimer laser. The laser has been used for nearly 20 years for the treatment of complex PAD. Most of the time, it is used over an existing guide wire. The initial use of the laser without a preceding wire was described by Professor Giancarlo Biamino. He termed this technique “step by step.” The laser catheter is positioned proximal to the SFA occlusion (with the wire withdrawn into the catheter). The laser is then activated for about 10 s a few mm proximal to the cap. Then the laser is again activated and gently passed into the cap (with the wire still inside the tip). After slowly penetrating a few (10 mm) mm, the wire can now gently probe the channel. Sometimes simply penetrating the fibrotic proximal cap will allow wire passage through the softer organized thrombus.