Chronic total occlusions in peripheral vasculature: techniques and devices

Peripheral artery disease continues to increase in an ever-aging society and consumes a significant part of health resources. Chronic total occlusions account for a significant portion of the lesions encountered by endovascular interventionalists. Unlike the coronary circulation, these occlusions are often long and associated with other features of complexity. The two primary issues concerning these lesions are the ability to safely achieve intimal angiographic success and the long-term durability of therapy. Traditionally, the use of percutaneous techniques was limited to certain anatomic subsets, such as stenosis or total occlusions. However, recent advances in wire technology, re-entry catheters, alternative crossing tools and atherectomy devices have increased the interventional armamentarium for this challenging disease subset. This article will focus on some of the techniques in crossing chronic total occlusions lesions, as well as the available devices to improve long-term patency.