Tools for Crossing Challenging CTOs

Dr. Jihad Mustapha is an interventional cardiologist who practices at Advanced Cardiovascular in Grand Rapids, MI. He used to perform the entire scope of interventional cardiology, until finding his passion in critical limb ischemia and dedicating his career to treating this complex disease. Advanced Cardiovascular has grown, and now includes a dedicated interventional cardiology department and a PAD/CLI specific department.

The basic principle for treating chronic total occlusions is to approach them from the best direction. This generally starts with an up and over technique to do the initial planning angiography. Dr. Mustapha then uses the wire and catheter technique, but limits his efforts to 5 minutes. If he can’t cross, he tries a new method. If he can cross but can’t reenter distally, then there are multiple methods to turn to, including reentry devices like the Outback and Pioneer. He emphasizes that when using reentry devices, you must measure the CTO and enter just after it ends, allowing no more than 1-2 mm of space between the cap and your reentry point. If it is impossible to reenter at that level, you should not use a reentry device and should turn to another method. The Chronic Total Occlusion crossing approach based on Plaque cap morphology (CTOP) classification is helpful when deciding how to safely approach a CTO or which technique to turn to, and Dr. Mustapha uses it in all his cases.

Next, we discuss pedal access. Dr. Mustapha acknowledges he hasn’t used reentry devices for years now, due to the fact that pedal access is so much quicker and works just as well. If a CTO has a complex CTOP classification, he doesn’t even try anterograde first, he just goes directly to pedal access and crosses retrograde. When he uses the retrograde approach to cross the CTO cap, he often finds the occlusion is not as long as he expects it to be, and also that he is intraluminal much more often than he initially anticipates. For long chronic total occlusions (CTOs), he starts with pedal access, crosses the CTO plaque cap, and continues through the occlusion, stopping just before the reentry point. If it pops through the cap, he then uses the tibiopedal artery minimally invasive retrograde revascularization (TAMI) technique, but if it does not, he comes anterograde and uses the flossing technique.

Finally, we discuss how to use the Wingman device, as well as tips for using the Jenali and modified Schmidt techniques. Finally, we discuss new devices coming soon in the CLI arena. Dr. Mustapha is excited about companies that are creating a 2-in-1 device that allows you to cross the CTO and then use it as a reentry device. Dr. Mustapha parts by telling listeners that CTOs are never friendly, whether long, short, calcified, or non-calcified, but as long as you anticipate this and go into a case expecting surprises, you’ll do well.