Donald L. Jacobs, MD FACS
Professor of Surgery
Program Director of Vascular Surgery
Saint Louis University, Saint Louis, Missouri, USA

Chronic Total Occlusions - CTOs

CTO – Improved success

Approach to CTOs
Supportive access
Key to crossing
Sheath support as close to occlusion as possible
Crossing starts with simple tools
Hydrophilic wire – Glidewire (Terumo)
Support catheter – Glidecath (Terumo)
Subintimal technique
80% success with these simple tools
 Bolia 1989, Lipsitz 2003

Subintimal Technique
Direct access and supportive sheaths
Iliac occlusions
 retrograde
Femoral occlusions
 Contra lateral retrograde, & up and over long sheath
 Braided sheaths
 Antegrade femoral with short er sheath
Infrageniculate
 Antegrade femoral with long sheath
 Contralateral retrograde, up and over with long sheath and/or
4fr coaxial long sheath inside your up and over sheath
Anticoagulation before manipulation in dissection

Subintimal Technique
Initiation
Push tip of catheter up to occlusion cap
Probe with Glidewire tip
Traversal
Wire looping in traversal is ideal
Backup with catheter as wire progresses
Small loop of 3-5cm best
Back-end of Glidewire
 Advance short distance – 1cm
 Follow with catheter
 Reverse wire back to soft tip and to advance subintimal
 potential perforation, small and typically self-limited

CTO of SFA crossed with
hydrophilic wire and 4 Fr cath
Cath injection confirms intraluminal
position in reconstituted distal vessel

7 Fr sheath
0.035 Quickcross catheter
(Spectranetics)
Glidewire
7 Fr sheath
6 Fr angled guide
0.035 Quickcross catheter
Glidewire

CTO wire options
 0.035 wire  Tip stiffness in small wires
 Glidewire  Grams deflection
 Straight or angled  Small stiff wires not
 Standard stiffness hydrophilic
 0.018 wire  Supportive hydrophilic 0.014
 Boston Scientific wires
 V-18  Boston Scientific
 0.014 wires specific for CTOs  PT Graphix extra support
 Asahi
 Confienza and Miracle Bros
 Medtronic
 Pursuader
 Cook
 Approach

Cordis Frontrunner
Spectranetics Laser
Safecross
Flowcardia Crosser

CTO technique
Traversal of occluded segment successful in over
90% of cases without adjunctive energy sources
Re-entry is the primary limitation to success
Useful maneuvers to achieve true lumen when
wire does not spontaneously enter true lumen
wire manipulation
directional catheters/guides
back-end of wire passage
angioplasty at distal end of occlusion
low-volume contrast injections in the dissection

Wire loop not extended
Beyond point of reconstituition
Distal reconstitution
via profunda collaterals

Cordis Outback
Medtronic Pioneer

• Monorail delivery over 0.014 wire
• 24G Nitinol needle allows for delivery of a
second 0.014” guide wire.
• Needle exits catheter ~ 7 mm below IVUS
transducer.
• Flexible shaft allows for contra lateral
approach.
• 7F Introducer sheath compatibility

Step 1: Guidewire entrapment Step 2: Catheter insertion Step 3: Catheter rotation
Step 4: Deploy needle Step 5: Pass guidewire to Step 6: Remove catheter
true lumen

true lumen
adventitia/media subintima

Chronic Iliac Occlusion
Baseline Final

Outback LTD Orientation Markers
®
‘L’ marker = Locate
Position image
intensifier to show
Outback adjacent
to true lumen
Point ‘L’ marker
toward true
lumen

Outback LTD Orientation Markers
®
‘T’ marker = Tune
• Move image intensifier
to orthogonal (90°)
view. Assure Outback
in ‘in-line’ with true
lumen
• Fine tune Outback to
display full ‘T’ ( )
marker

Outback Catheter L View
Outback Catheter T View
Catheter in subintimal space

Conclusions
Complex total occlusions can be approached
with a high likelihood of procedural success
with realtively simple crossing tools
Variety of devices available to increase the
likelihood of success when hydrophilic
guidewires fail
Re-entry devices address the most common
reason for failure – subintimal wire trapping
Should increase success rates for CTO crossing
to well over 90%