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Femoropopliteal Chronic Total Occlusions: Approach and Considerations for Crossing and Intervention

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Peripheral Arterial Interventions

Part of the book series: Contemporary Cardiology ((CONCARD))

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Abstract

Femoropopliteal artery disease accounts for a large proportion of peripheral artery endovascular interventions. Chronic total occlusions are highly prevalent in this vascular bed and pose a technical challenge for crossing and intervention. We discuss a detailed, hierarchal approach combined with flexibility and thorough pre-procedural planning to achieve reproducible procedural success.

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Abbreviations

BTK:

Below-the-knee

CA:

Contrast angiography

CCD:

CTO crossing device

CFA:

Common femoral artery

CTA:

Computed tomography angiography

CTO:

Chronic total occlusion

DSA:

Digital subtraction angiography

DUS:

Duplex ultrasound

FP:

Femoropopliteal

IVUS:

Intravascular ultrasound

MRA:

Magnetic resonance angiography

PCTO:

Peripheral chronic total occlusion

RC:

Rutherford classification

RCART:

Reverse controlled antegrade-retrograde tracking

SFA:

Superficial femoral artery

SI:

Subintimal

STAR:

Subintimal tracking and reentry

WC:

Wire catheter

References

  1. Goodney PP, Beck AW, Nagle J, Welch HG, Zwolak RM. National trends in lower extremity bypass surgery, endovascular interventions, and major amputations. J Vasc Surg. 2009;50(1):54–60. https://doi.org/10.1016/j.jvs.2009.01.035.

    Article  PubMed  Google Scholar 

  2. Ho KJ, Owens CD. Diagnosis, classification, and treatment of femoropopliteal artery in-stent restenosis. J Vasc Surg. 2017;65(2):545–57. https://doi.org/10.1016/j.jvs.2016.09.031.

    Article  PubMed  Google Scholar 

  3. Hamur H, Onk OA, Vuruskan E, et al. Determinants of chronic total occlusion in patients with peripheral arterial occlusive disease. Angiology. 2017;68(2):151–8. https://doi.org/10.1177/0003319716641827.

    Article  CAS  PubMed  Google Scholar 

  4. Techniques in vascular and interventional radiology—Journal—Elsevier. https://www.journals.elsevier.com/journals.elsevier.com/techniques-in-vascular-and-interventional-radiology. Accessed 30 Aug 2021.

  5. Kondapalli A, Jeon-Slaughter H, Lu H, et al. Comparative assessment of patient outcomes with intraluminal or subintimal crossing of infrainguinal peripheral artery chronic total occlusions. Vasc Med. 2018;23(1):39–45. https://doi.org/10.1177/1358863X17735192.

    Article  PubMed  Google Scholar 

  6. Guiding principles for chronic total occlusion percutaneous coronary intervention. Circulation. https://www.ahajournals.org/doi/10.1161/CIRCULATIONAHA.119.039797. Accessed 30 Aug 2021.

  7. Banerjee S, Sarode K, Mohammad A, et al. Femoropopliteal artery stent thrombosis. Circ Cardiovasc Interv. 2016;9(2):e002730. https://doi.org/10.1161/CIRCINTERVENTIONS.115.002730.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  8. Banerjee S, Sarode K, Patel A, et al. Comparative assessment of guidewire and microcatheter vs a crossing device-based strategy to traverse infrainguinal peripheral artery chronic total occlusions. J Endovasc Ther. 2015;22(4):525–34. https://doi.org/10.1177/1526602815587707.

    Article  PubMed  Google Scholar 

  9. Chou H-H, Huang H-L, Hsieh C-A, et al. Outcomes of endovascular therapy with the controlled antegrade retrograde subintimal tracking (CART) or reverse CART technique for long infrainguinal occlusions. J Endovasc Ther. 2016;23(2):330–8. https://doi.org/10.1177/1526602816630533.

    Article  PubMed  Google Scholar 

  10. Brilakis ES, Grantham JA, Rinfret S, et al. A percutaneous treatment algorithm for crossing coronary chronic total occlusions. JACC Cardiovasc Interv. 2012;5(4):367–79. https://doi.org/10.1016/j.jcin.2012.02.006.

    Article  PubMed  Google Scholar 

  11. Saab F, Jaff MR, Diaz-Sandoval LJ, et al. Chronic total occlusion crossing approach based on plaque cap morphology: the CTOP classification. J Endovasc Ther. 2018;25(3):284–91. https://doi.org/10.1177/1526602818759333.

    Article  PubMed  Google Scholar 

  12. Banerjee S, Shishehbor MH, Mustapha JA, et al. A percutaneous crossing algorithm for femoropopliteal and tibial artery chronic total occlusions (PCTO algorithm). J Invasive Cardiol. 2019;31(4):18.

    Google Scholar 

  13. Sheeran D, Wilkins LR. Long chronic total occlusions: revascularization strategies. Semin Interv Radiol. 2018;35(5):469–76. https://doi.org/10.1055/s-0038-1676343.

    Article  Google Scholar 

  14. Manzi M, Cester G, Palena LM, Alek J, Candeo A, Ferraresi R. Vascular imaging of the foot: the first step toward endovascular recanalization. Radiographics. 2011;31(6):1623–36. https://doi.org/10.1148/rg.316115511.

    Article  PubMed  Google Scholar 

  15. Li X-M, Li Y-H, Tian J-M, et al. Evaluation of peripheral artery stent with 64-slice multi-detector row CT angiography: prospective comparison with digital subtraction angiography. Eur J Radiol. 2010;75(1):98–103. https://doi.org/10.1016/j.ejrad.2009.03.032.

    Article  PubMed  Google Scholar 

  16. Liu J, Zhang N, Fan Z, et al. Image quality and stenosis assessment of non-contrast-enhanced 3-T magnetic resonance angiography in patients with peripheral artery disease compared with contrast-enhanced magnetic resonance angiography and digital subtraction angiography. PLoS One. 2016;11(11):e0166467. https://doi.org/10.1371/journal.pone.0166467.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  17. Klein AJ, Pinto DS, Gray BH, et al. SCAI expert consensus statement for femoral-popliteal arterial intervention appropriate use. Catheter Cardiovasc Interv. 2014;84(4):529–38. https://doi.org/10.1002/ccd.25504.

    Article  PubMed  Google Scholar 

  18. Klein AJ, Jaff MR, Gray BH, et al. SCAI appropriate use criteria for peripheral arterial interventions: an update. Catheter Cardiovasc Interv. 2017;90(4):E90–E110. https://doi.org/10.1002/ccd.27141.

    Article  PubMed  Google Scholar 

  19. Niazi K, Farooqui F, Devireddy C, Robertson G, Shaw RE. Comparison of hydrophilic guidewires used in endovascular procedures. J Invasive Cardiol. 2009;21(8):397–400.

    PubMed  Google Scholar 

  20. Venkatachalam S, Bunte M, Monteleone P, Lincoff A, Maier M, Shishehbor MH. Combined antegrade-retrograde intervention to improve chronic total occlusion recanalization in high-risk critical limb ischemia. Ann Vasc Surg. 2014;28(6):1439–48. https://doi.org/10.1016/j.avsg.2014.01.011.

    Article  PubMed  Google Scholar 

  21. Yilmaz S, Sindel T, Yegin A, Lüleci E. Subintimal angioplasty of long superficial femoral artery occlusions. J Vasc Interv Radiol. 2003;14(8):997–1010. https://doi.org/10.1097/01.rvi.000008261.05622.b8.

    Article  PubMed  Google Scholar 

  22. Fanelli F, Cannavale A. Retrograde recanalization of complex SFA lesions indications and techniques. J Cardiovasc Surg. 2014;55(4):465–71.

    CAS  Google Scholar 

  23. Schmidt A, Bausback Y, Piorkowski M, et al. Retrograde recanalization technique for use after failed antegrade angioplasty in chronic femoral artery occlusions. J Endovasc Ther. 2012;19(1):23–9. https://doi.org/10.1583/11-3645.1.

    Article  PubMed  Google Scholar 

  24. Shin S, Kim S, Ko Y-G, Hong M-K, Jang Y, Choi D. Retrograde distal superficial femoral artery approach in the supine position for chronic superficial femoral artery occlusion. Korean Circ J. 2014;44(3):184–8. https://doi.org/10.4070/kcj.2014.44.3.184.

    Article  PubMed  PubMed Central  Google Scholar 

  25. Tasic M, Sreckovic MJ, Jagic N, Miloradovic V, Nikolic D. Knuckle technique guided by intravascular ultrasound for in-stent restenosis occlusion treatment. Postępy Kardiol Interwencyjnej. 2015;11(1):58. https://doi.org/10.5114/pwki.2015.49188.

    Article  PubMed  PubMed Central  Google Scholar 

  26. Spinosa DJ, Leung DA, Harthun NL, et al. Simultaneous antegrade and retrograde access for subintimal recanalization of peripheral arterial occlusion. J Vasc Interv Radiol. 2003;14(11):1449–54. https://doi.org/10.1097/01.rvi.0000096764.74047.21.

    Article  PubMed  Google Scholar 

  27. Cao J, Lu H-T, Wei L-M, Zhao J-G, Zhu Y-Q. Rendezvous technique for recanalization of long-segmental chronic total occlusion above the knee following unsuccessful standard angioplasty. Vascular. 2016;24(2):157–65. https://doi.org/10.1177/1708538115589049.

    Article  CAS  PubMed  Google Scholar 

  28. Michael TT, Papayannis AC, Banerjee S, Brilakis ES. Subintimal dissection/reentry strategies in coronary chronic total occlusion interventions. Circ Cardiovasc Interv. 2012;5(5):729–38. https://doi.org/10.1161/CIRCINTERVENTIONS.112.969808.

    Article  PubMed  PubMed Central  Google Scholar 

  29. Nihei T, Yamamoto Y, Kudo S, et al. Impact of the intracoronary rendezvous technique on coronary angioplasty for chronic total occlusion. Cardiovasc Interv Ther. 2017;32(4):365–73. https://doi.org/10.1007/s12928-016-0421-1.

    Article  PubMed  Google Scholar 

  30. Goltz JP, Anton S, Wiedner M, Barkhausen J, Stahlberg E. Simultaneous antegrade-retrograde subintimal revascularization of a femoropopliteal chronic total occlusion by a reentry device-facilitated puncture of a retrogradely inserted balloon. J Endovasc Ther. 2017;24(4):521–4. https://doi.org/10.1177/1526602817707742.

    Article  PubMed  Google Scholar 

  31. McCoach CE, Armstrong EJ, Singh S, et al. Gender-related variation in the clinical presentation and outcomes of critical limb ischemia. Vasc Med. 2013;18(1):19–26. https://doi.org/10.1177/1358863X13475836.

    Article  PubMed  PubMed Central  Google Scholar 

  32. Iida O, Soga Y, Yamauchi Y, et al. Anatomical predictors of major adverse limb events after infrapopliteal angioplasty for patients with critical limb ischaemia due to pure isolated infrapopliteal lesions. Eur J Vasc Endovasc Surg. 2012;44(3):318–24. https://doi.org/10.1016/j.ejvs.2012.05.011.

    Article  CAS  PubMed  Google Scholar 

  33. Fujii M, Terashi H. Angiosome and tissue healing. Ann Vasc Dis. 2019;12(2):147–50. https://doi.org/10.3400/avd.ra.19-00036.

    Article  PubMed  PubMed Central  Google Scholar 

  34. Ruzsa Z, Nemes B, Bánsághi Z, et al. Transpedal access after failed anterograde recanalization of complex below-the-knee and femoropoliteal occlusions in critical limb ischemia. Catheter Cardiovasc Interv. 2014;83(6):997–1007. https://doi.org/10.1002/ccd.25262.

    Article  PubMed  Google Scholar 

  35. Mustapha JA, Saab F, McGoff T, et al. Tibio-pedal arterial minimally invasive retrograde revascularization in patients with advanced peripheral vascular disease: the TAMI technique, original case series. Catheter Cardiovasc Interv. 2014;83(6):987–94. https://doi.org/10.1002/ccd.25227.

    Article  CAS  PubMed  Google Scholar 

  36. Palena LM, Manzi M. Extreme below-the-knee interventions: retrograde transmetatarsal or transplantar arch access for foot salvage in challenging cases of critical limb ischemia. J Endovasc Ther. 2012;19(6):805–11. https://doi.org/10.1583/JEVT-12-3998R.1.

    Article  PubMed  Google Scholar 

  37. Mustapha JA, Saab F, McGoff TN, Finton S, Adams G, Mullins JR. Chronic total occlusions: association between characteristics and mid-term outcomes in critical limb ischemia. J Crit Limb Ischem. 2021;1:7.

    Google Scholar 

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Acknowledgments

We would like to thank the patients and members of the healthcare team who have allowed us to deliver care and to continue learning. Our deepest gratitude to prior innovators in the field so that we can continue to build upon their work and progress.

Disclosures

Michael Vu—None; Subhash Banerjee: Consultant for Medtronic, Cordis, Kaneka and Institutional research grants from Boston Scientific Corporation and Chiesi.

Funding

None.

Author information

Authors and Affiliations

  1. Methodist Health System of Dallas, Dallas, TX, USA

    Michael H. Vu

  2. University of Texas Southwestern Medical Center, Dallas, TX, USA

    Subhash Banerjee

  3. Veterans Affairs North Texas Health Care System, Dallas, TX, USA

    Subhash Banerjee

Authors
  1. Michael H. Vu
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  2. Subhash Banerjee
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Corresponding author

Correspondence to Subhash Banerjee .

Editor information

Editors and Affiliations

  1. Midwest Cardiovascular Research Foundation, Davenport, IA, USA

    Nicolas W. Shammas

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Vu, M.H., Banerjee, S. (2022). Femoropopliteal Chronic Total Occlusions: Approach and Considerations for Crossing and Intervention. In: Shammas, N.W. (eds) Peripheral Arterial Interventions. Contemporary Cardiology. Springer, Cham. https://doi.org/10.1007/978-3-031-09741-6_14

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  • DOI: https://doi.org/10.1007/978-3-031-09741-6_14

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  • Publisher Name: Springer, Cham

  • Print ISBN: 978-3-031-09740-9

  • Online ISBN: 978-3-031-09741-6

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