Feasibility of an Intravascular Ultrasound-First Strategy for Below-the-Knee Chronic Total Occlusion Lesions

Endovascular therapy for below-the-knee chronic total occlusion (BTK CTO) lesions is technically challenging, and retrograde approaches using distal puncture are often required. This study aimed to evaluate the feasibility of an intravascular ultrasound (IVUS)-first strategy in BTK CTO lesions.

In this single-center retrospective study, 263 patients with chronic limb-threatening ischemia undergoing endovascular therapy for BTK CTO lesions between January 2022 and June 2025 were screened. After excluding stenotic lesions and cases treated with angiography-guided antegrade approach alone, 63 lesions were analyzed. Technical success and procedural complications were evaluated. Among lesions treated with an IVUS-first strategy, a subgroup analysis comparing IVUS-only and crossover cases was performed.

Among 63 lesions, 34 were treated with an IVUS-first strategy, and 29 underwent primary distal puncture. Technical success showed a trend toward improvement in the IVUS-first group (91.2% vs. 72.4%, p = 0.051), while complication rates were similar (5.9% vs. 13.8%, p = 0.29). In the IVUS-first group, antegrade-only completion was achieved in 70.6% of lesions, whereas 29.4% required crossover to distal puncture. Severe calcification was significantly more frequent in crossover cases (90.0% vs. 29.2%, p = 0.002).

An IVUS-first strategy enabled antegrade-only completion in approximately 70% of BTK CTO lesions and may help reduce the need for distal puncture in selected cases.