Comparative Assessment of Crossing and Reentry Devices in Treating Chronic Total Occlusions for Femoropopliteal and Below-the-Knee Interventions

Abstract

Chronic total occlusions (CTOs) are widely prevalent in peripheral arterial interventions. It is estimated that CTOs are encountered in 25–50% of all lesions treated [1]. Multiple predictors of failure to cross CTO have been reported including lesion length, the presence of side branches at the proximal or distal cap, heavily calcified vessels, and operator’s experience. A failure rate of up to 50% has been reported when intraluminal crossing of a CTO was attempted with conventional guidewires [2, 3] but significantly improved with specialized crossing devices into the 70% range [3]. A subintimal approach is likely to have a higher initial success rate in the 80% range, but this is dependent on operator’s familiarity with reentry devices and lack of severe calcification at the reentry site. Also a higher loss of patency is seen with an initial subintimal approach on intermediate-term follow-up [4–6]. In all comers, the overall technical failure rate remains high at approximately 20% with conventional guidewires and balloons [2, 7]. In this chapter we review published data on CTO devices in peripheral interventions. Randomized comparisons of the effectiveness and safety of these devices in treating CTO are lacking. We therefore present observational studies and non-randomized comparisons between these devices while acknowledging the significant limitations of the data.