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Crossing Total Occlusions: Navigating Towards Recanalization
Aimée Sakes1, Evelyn Regar2, Jenny Dankelman3
1Department of Biomechanical Engineering, Faculty of Mechanical, Maritime and Materials Engineering, Delft University of Technology, Mekelweg 2, 2628 CD, Delft, The Netherlands. a.sakes@tudelft.nl.
Insights
Crossing chronic total occlusions (CTOs) is challenging. This review categorizes CTO crossing devices by their approach, highlighting advantages and disadvantages for future innovations in percutaneous interventions.
Area of Science:
- Cardiovascular Interventions
- Medical Device Technology
- Biomedical Engineering
Background:
- Chronic total occlusions (CTOs) present significant challenges in percutaneous coronary interventions.
- Successful guidewire crossing into the distal true lumen is often hindered by device buckling, poor visualization, and navigation limitations.
Purpose of the Study:
- To systematically review existing and novel devices for crossing CTOs.
- To identify future research directions for improving CTO intervention success rates.
Main Methods:
- A comprehensive literature search was conducted using Scopus and Espacenet databases.
- Keywords focused on medical and instrument-related terms for CTO crossing devices.
- 45 patents and 16 articles were selected after initial screening of over 840 patents and 69 articles.
Main Results:
- Crossing devices were classified into three categories based on the crossing path determinant: device, environment, or user.
- Each crossing strategy (e.g., device-based, environment-guided, user-controlled) exhibits unique benefits and drawbacks.
- Identified devices include straight/angled crossing, least resistance, tissue selective, centerline, subintimal, directly steered, and sensor-enhanced crossing.
Conclusions:
- Future CTO crossing devices should ideally integrate multiple crossing strategies.
- Combining high force application (device approach) with active steering (user approach) is recommended.
- Incorporating intravascular imaging or centerline/least resistance navigation enhances safety and efficacy.
Abstract:
Chronic total occlusions (CTOs) represent the "last frontier" of percutaneous interventions. The main technical challenges lies in crossing the guidewire into the distal true lumen, which is primarily due to three problems: device buckling during initial puncture, inadequate visualization, and the inability to actively navigate through the CTO. To improve the success rate and to identify future research pathways, this study systematically reviews the state-of-the-art of all existing and invented devices for crossing occlusions. The literature search was executed in the databases of Scopus and Espacenet using medical and instrument-related keyword combinations. The search yielded over 840 patents and 69 articles. After scanning for relevancy, 45 patents and 16 articles were included. The identified crossing devices were subdivided based on the determinant for the crossing path through the occlusion, which is either the device (straight and angled crossing), the environment (least resistance, tissue selective, centerline, and subintimal crossing) or the user (directly steered and sensor enhanced crossing). It was found that each crossing path is characterized by specific advantages and disadvantages. For a future crossing device, a combination of crossing paths is suggested were the interventionist is able to exert high forces on the CTO (as seen in the device approach) and actively steer through the CTO (user: directly steered crossing) aided by intravascular imaging (user: sensor enhanced crossing) or an intrinsically safe device following the centerline or path of least resistance (environment: centerline crossing or least resistance crossing) to reach the distal true lumen.
