Rock-Hard Chronic Thrombotic Occlusion and Its Management in Endovascular Interventions

Endovascular recanalization for patient with peripheral arterial disease and the end of its spectrum critical limb ischemia (CLI) has become a preferred method of revascularization due to advancement of techniques and equipment, allowing reduction of limb amputations while maintaining a minimally invasive approach compared to surgical approaches. Interventionalists have undertaken a progressively increasing complexity of diseased vessels in the hopes of providing inline unobstructed flow through occlusions for patients with claudication as well as direct flow to a nonhealing wound in patients with CLI. One of the major roadblocks encountered in lower extremity recanalization procedures is managing severely calcified chronic thrombotic occlusions which decrease luminal revascularization, ultimately increasing use of adjunctive interventions such as subintimal tracking, reentry device utilization, and stent placement. Understanding the histopathology and classification of lower extremity calcifications, imaging findings, and escalation of equipment use provides a thorough background in dealing with these specific cases.