A Percutaneous Crossing Algorithm for Femoropopliteal and Tibial Artery Chronic Total Occlusions (PCTO Algorithm)

Area of Science:

• Vascular Surgery
• Interventional Radiology
• Medical Imaging

Background:

• Peripheral artery chronic total occlusions (PCTOs) present a significant challenge in endovascular interventions.
• Successful crossing of PCTOs is critical for procedure success and complication avoidance.

Purpose of the Study:

• To outline a contemporary, ultrasound-based approach for crossing femoropopliteal (FP) PCTOs.
• To provide a systematic strategy for optimizing guidewire selection and re-entry techniques.

Main Methods:

• Review of prospectively collected case reports, published evidence, and expert consensus.
• Description of optimal imaging and key angiographic/ultrasound features.
• Development of a hierarchical procedural algorithm.

Main Results:

• Detailed guidance on lesion imaging and selection of antegrade, retrograde, or hybrid crossing techniques.
• Strategies for initial guidewire selection, escalation, and dissection re-entry.
• Case examples illustrating the application of the described methods.

Conclusions:

• The proposed ultrasound-based algorithm provides a systematic strategy for crossing PCTOs.
• Implementation of this approach can enhance crossing efficiency, treatment success, and patient safety.