Strategies for Crossing
Complex SFA Occlusions
D. Chris Metzger, MD, FACC
Director, Cardiac & Peripheral Cath Labs
Medical Director, Clinical Research
Cardiovascular Associates/ Wellmont Holston
Valley Medical Center
Kingsport, TN
SALSAL 2009

OVERVIEW
Background/ Rationale for CTO PVI
Planning procedure
Access considerations
Tools
Techniques
Illustrative Cases

CTO’s in 2009
Success rates are much higher with
experienced operators and recent
advances in technology
Successful/ proper endovascular
treatment of CTO’s are frontline therapy
for majority of patients (and don’t preclude
future surgical treatment)

Planning for CTO PVI
Etiology/ duration of CTO?
Symptom severity to patient?
Patient and family well-informed? Patient,
staff, and doc well prepared? (Foley, etc.)
Entry and re-entry points stentable?
Adjunctive therapy? (EPD, atherectomy,..)
Access route

CTO PVI Considerations
Do NOT want to extend occlusion by
dissecting beyond original re-entry point
Anticoagulation (Heparin until cross, then
consider heparin gtt or bivalirudin)
Severe disease in re-entry point, or
occlusion and re-entry at large collaterals?
Respect the profunda, CFA, & politeals!
Patience req’d! Can retry again prn

ACCESS to CTO
Contralateral in majority of cases
Antegrade (~poor choice if proximal dz.)
Popliteal (use w/ roadmap from above)
Pedal (experienced operators)
Brachial (~impractical because of length of
most devices insufficient)
ROADMAPS (through sheath to visualize
distal filling via collaterals)

CTO PVI Techniques
Identify the “nub”and re-entry points!
Start with angled catheter and Glidewire
Ideally hope to stay within lumen (preserves
options for adjunctive therapy)
XC wires, adequate length transfer catheters
If loop forms, advance, follow with catheter, re-
advance wire (loop<vessel width)- OK to exert
force on cath or gw
Confirm intraluminal position carefully

My “Must-Have Tools”
Glidewires (straight and angled)
Quick-Cross catheters (straight & angled)
Re-entry devices
Laser
Embolic PD’s (Nav 6 Emboshield, Spider)
Viabahn covered stents
Supera stents
Pinnacle Destination and Raabe sheaths

CTO TOOLS
Tools to cross
proximal cap
Tools to re-enter
lumen of distal vessel

ID the nub; accessory devices

More Nub Hunting

OUTBACK Re-entry Tips
Shortens procedure times!
Use quick cross to XC for 0.014 XC wire
Re-enter in first normal segment after CTO
“L” and “T” orientations w/ oblique views
Wire should pass EASILY
If not, redirect/retry OR withdraw needle
Remember to retract needle before removing
Confirm and XC with Quick cross
Sometimes coronary balloons needed first

ANTEGRADE ACCESS

RSu- Popliteal Access for 1995 CTO

ADJUNCTIVE RX for Bad Dz

CONCLUSIONS
Case selection, careful planning, patience,
persistence, resourcefulness, good
technique, operator experience, and
appropriate use of adjunctive tools leads
to a high success rate for treating SFA
CTO’s with endovascular therapy

POPLITEAL ACCESS

OutbackLTD Re-Entry Catheter

Re-Entry
Deploy
Deploy
cannula in
cannula in
either “T” or
either “T” or
“L” view
“L” view
Advance wire
Advance wire
Retract needle
Retract needle
Remove
Remove
device
device

Achieving Acute Success and
Durable Results with Complete
Total Occlusion?
Christopher J. Kwolek, MD FACS
Harvard Medical School
Division of Vascular and Endovascular Surgery
Massachusetts General Hospital