Crossing Algorithm for Infrainguinal Chronic Total Occlusions: An Interdisciplinary Expert Opinion Statement
Grigorios Korosoglou1, Andrej Schmidt2, Michael Lichtenberg3
1GRN Hospital Weinheim, Cardiology and Vascular Medicine, Weinheim, Germany.
Insights
A new algorithm standardizes endovascular treatment for peripheral chronic total occlusions (CTOs). This approach guides clinicians through imaging, wiring, and advanced techniques for improved patient outcomes.
Area of Science:
- Vascular Surgery
- Interventional Cardiology
- Endovascular Procedures
Background:
- Peripheral chronic total occlusions (CTOs) present significant challenges in endovascular treatment.
- Current endovascular procedures for CTOs lack standardization, potentially impacting outcomes.
Purpose of the Study:
- To introduce a novel crossing algorithm for the endovascular treatment of peripheral CTOs.
- To standardize and harmonize endovascular procedures for CTOs, improving clinical practice.
Main Methods:
- The algorithm involves detailed pre-procedural imaging (duplex sonography, CT/MR angiography) for access site selection.
- It includes comprehensive angiographic evaluation of lesion morphology, collaterals, and distal vessel quality.
- Strategies encompass antegrade and retrograde wiring, advanced bidirectional techniques, and re-entry devices.
Main Results:
- The algorithm outlines a systematic approach from access site selection to guidewire (GW) passage and externalization.
- It details criteria for stopping antegrade attempts and managing retrograde access.
- The proposed method includes advanced techniques and decision-making for complex CTO cases.
Conclusions:
- Implementation of this algorithm is expected to improve vessel- and patient-specific outcomes in endovascular CTO treatment.
- The study emphasizes the need for continuous collaboration and future research among endovascular specialists.
Abstract:
A crossing algorithm was developed for the endovascular treatment of peripheral chronic total occlusive lesions (CTOs) to educate, guide, and appropriately influence clinical practice aiming at harmonization and standardization of endovascular procedures. The following steps are proposed: One, duplex sonography and if required computed tomography or magnetic resonance angiography for the selection of the optimal access site. Two, angiographic evaluation of the proximal/distal cap morphology, presence of collaterals at the origin of the proximal cap and at the distal vessel refilling site. In addition, evaluation of distal vessels, including their diameters and quality, and the presence of calcification or stents within the occlusion zone. Three, antegrade wiring strategies, guidewire (GW) and support catheter technology, as well as GW escalation strategies. Stop the antegrade attempt depending on clinical indication for peripheral artery disease treatment and the presence of retrograde options. Four, retrograde access site, support catheter, or sheath insertion and wiring technology from distally. Five, considering strategy change when progress cannot by achieved, using advanced bidirectional techniques and re-entry devices. Six, in case of successful GW passage from retrograde, GW externalization and treatment from antegrade. Management of the retrograde access by internal or external hemostasis at the end of the procedure. Alternatively, stop the procedure if no progress can be obtained within 3 hours or in case of specific complications. By establishing the algorithm in the daily routine of endovascular specialists, improvements in vessel- and patient-specific outcomes are anticipated. In addition, future research, and continuous collaboration between experts is warranted.
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