Intraluminal crossing approach may benefit some patients with peripheral CTOs

CHICAGO — Operators usually try the subintimal crossing approach when performing endovascular revascularization in patients with chronic total occlusion of a peripheral artery, but the intraluminal approach may be better in some cases, an expert said at AMP: The Amputation Prevention Symposium.

CTOs are a frequent cause for a limb not being revascularized, so if one technique does not appear feasible, another should be considered, Mehdi H. Shishehbor, DO, MPH, PhD, director of endovascular services at Cleveland Clinic and a member of the Cardiology Today’s Intervention Editorial Board, said during a presentation.

Mehdi H. Shishehbor

“The problem is that we have very little data in this area,” Shishehbor said.

One consideration is that it may not make sense to treat acute CTOs and chronic CTOs the same way because an acute CTO is primarily made up of soft lipids, thrombus, fibrin and proteoglycans, whereas a chronic CTO mostly consists of dense collagen and calcium, which means an acute CTO can more easily be crossed than a chronic one.

“In the same CTO, depending on the chronicity and the length, we may be dealing with both processes at the same time,” he said. The idea behind the subintimal approach is “to get behind the plaque in the subintimal space, but you do not cross into the media. We don’t want to damage the media.”

CTOs are more likely to reocclude and restenose than other types of lesions, especially if they are long, according to Shishehbor, which raises the question: “Is this a reflection of the fact that we are going subintimal, or is it a reflection of the disease burden?” The answer is not known, but if it is the latter, patients with long CTOs might not do well regardless of approach, he said.

Pros of the intraluminal approach include that atherectomy is more likely to be successful and stenting is more likely not to be needed, whereas pros of the subintimal approach include that it is faster and has a high rate of technical success, according to Shishehbor.

Cons of the intraluminal approach include that it is not uniformly successful and it is difficult to tell if the wire remains in the true lumen throughout the process, whereas cons of the subintimal approach include that an advanced skill set is needed, there is a steep learning curve, 10% to 15% of such procedures require a re-entry device, and adjunctive stenting is often required, he said.

Most research on this topic has been done on procedures with plain balloons, but there are little data on procedures with newer technologies such as drug-coated balloons and drug-eluting stents, according to Shishehbor. – by Erik Swain

Reference:

Shishehbor MH. In CLI, not all CTOs are created equal. Presented at: AMP: The Amputation Prevention Symposium; Aug. 10-13, 2016; Chicago.

Disclosure: Shishehbor reports unpaid education and consulting for Abbott Vascular, Bard, Covidien, Gore, Medtronic and Spectranetics.