Chronic Total Occlusion Crossing Approach Based on Plaque Cap Morphology: The CTOP Classification

Area of Science:

• Vascular Surgery
• Interventional Cardiology
• Medical Imaging

Background:

• Chronic total occlusions (CTOs) present challenges in endovascular interventions.
• Predictive tools for successful CTO crossing are crucial for optimizing treatment strategies.

Purpose of the Study:

• To introduce the plaque cap morphology (CTOP) classification system for chronic total occlusions (CTOs).
• To evaluate the CTOP system's efficacy in predicting successful lesion crossing during endovascular interventions.

Main Methods:

• Retrospective analysis of 142 CTO interventions in 114 patients with peripheral artery disease.
• CTO cap morphology classified into four types (I-IV) based on angiography and duplex ultrasonography.
• Correlation of CTOP types with procedural success, crossing techniques, and access conversion.

Main Results:

• CTOP type I lesions were most amenable to antegrade crossing with less calcification.
• CTOP type IV lesions were most challenging for antegrade crossing, often requiring retrograde tibiopedal access.
• Lesion length >10 cm, severe calcification, and CTOP types II, III, and IV were associated with increased need for alternate access strategies.

Conclusions:

• The CTOP classification system effectively predicts CTO crossing difficulty and guides procedural approach.
• Retrograde tibiopedal access is beneficial for complex CTOs (types II-IV), long lesions, and severe calcification.
• CTOP classification aids in selecting optimal strategies for endovascular CTO treatment.