BackTable / VI / Podcast / Transcript #305

Podcast Transcript: Tools for Crossing Challenging CTOs

with Dr. Jihad Mustapha

In this episode, host Dr. Sabeen Dhand interviews Dr. Jihad Mustapha, interventional cardiologist, about new technology for treating CLI, including CTOP classification, CTO crossing techniques, and reentry devices. You can read the full transcript below and listen to this episode here on BackTable.com.

(1) Basic CTO Techniques

(2) The Importance of CTOP Classification

(3) Re-Entry Devices vs. Pedal Access for CTOs

(4) Re-entry Devices

(5) Re-entry Devices Below-the-Knee (BTK)

(6) Re-Entry Devices with Long Subintimal Tracts

(7) Re-Entry Devices for Iliac Occlusions at the Iliac Bifurcation

(8) Future Devices

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[Dr. Sabeen Dhand]
…I'm Sabeen as your host today, and I'm so happy and glad to welcome back a great friend, an extremely talented cardiologist, Dr. Jihad Mustapha from ACV in Grand Rapids, Michigan. How are you doing, man?

[Dr. Jihad Mustapha]
I'm doing very well Sabeen. Thank you and Aaron for putting this together because this is something that is extremely needed. We all need it, including myself. We always learn something new when you put out something that we never thought of before, and then suddenly you discuss it and it becomes part of our practice. Thank you for doing all the work.

[Dr. Sabeen Dhand]
Absolutely. Thank you for taking the time. We love learning from you, Jihad. You've done so much. The last time we sat and talked together on BackTable was almost three years ago. We talked about building a limb salvage program. That was episode 60 for all our listeners. A really, really good episode about building that program. Now it's three years later. What have you been up to? What has changed? What is going on in your life, Jihad?

[Dr. Jihad Mustapha]
These last three years have been phenomenal three years because I definitely shifted from being a cardiologist into a CLI specialist. Stopped doing-- not cardiology in general, but advanced cardiology, and focused primarily on critical limb ischemia, and PAD. That field, CLI, is actually much bigger than I thought. Quite frankly, it's almost, you can say at one point it will be its own specialty because there's so much in it that we don't know, so much that we're knowing. I dedicated myself to it the last three or four years have really changed my life in a very positive way.

[Dr. Sabeen Dhand]
That's great. I'm pretty sure everyone knows who you are, but for our listeners who don't, can you describe what ACV is and what is your general practice like?

[Dr. Jihad Mustapha]
ACV is Advanced Cardiovascular and our practice initially started as a practice that focused primarily on critical limb ischemia and arterial disease and a small part of it was coronary artery disease. Then as we grew and we got more cardiologists and then we have now almost, not split, but have a cardiology department with interventional cardiology in it. Then we have PAD/CLI components.

It's cool because our PAs, doctors, everyone that is caring for patients directly have become extremely knowledgeable about both, and then add venous into that. I really enjoy reading in H&Ps because the H&Ps have become so long and so big because you have to cover the cardiology components, PAD, and venous CLI. We have grown to the point that we have encompassed the entire cardiovascular system in-depth and that made us that much better doctors.

[Dr. Sabeen Dhand]
You've expanded too. You're even close to me now, close to-- you have a Vegas outpost and everything. It's really, really great what you're doing Jihad. Today, we're going to be focusing on these complex revascularization, lower extremity revascularization, and utilizing some devices that can help us in particularly when we're revascularizing a chronic occlusion.

[Dr. Jihad Mustapha]
Yes.

(1) Basic CTO Techniques

[Dr. Sabeen Dhand]
Now, my question for you just, to begin with, is what are some basic techniques that we can just list and talk about that you use when you see a long chronic total occlusion? What are some things that any operator should be comfortable with?

[Dr. Jihad Mustapha]
CTOs are never friendly. Long, short, classified, and unclassified. As long as you accept that right off the bat and knowing that you're going into a CTO and expect the unexpected, you're going to do well. The basics of chronic total occlusions is approaching it from the best directions for instance. Up and over in the United States still actually the primary methods.

We do initial angiography up and over, take a look at the CTO, and then we do the wire catheter technique and try to cross with that and then, quite frankly, we try for maybe five minutes. If you don't make headways in five minutes, we tend to shift to alternative methods. If we make headways and we cross the CTO, but we can't re-enter distally, then we have multiple methods.

Outbacks, Pioneers are really great devices, and I had the luxury of working with them for actually a long time and got to study them very well. They do help in situations where you have to re-enter in SFA or popliteal. It becomes more problematic when you go to P3 or the popliteal. If you can re-enter without them, it's great but if you have to re-enter with them, we can discuss the pitfalls the good, and the bad, tips and tricks.

Finally, one thing that I'd like to caution everyone of, CTOs are tricky. If you have a CTO that you measure and it's 150 millimeters, you should re-enter at 151 or 152 or something like this.

[Dr. Sabeen Dhand]
Not like 6 to 7 centimeters past the reconstituted segment.

[Dr. Jihad Mustapha]
Yes. If you can't do that, then you have to find another way. We can talk about that as we go.

[Dr. Sabeen Dhand]
We briefly touched on that. There's nothing like when you get really, I'm going to quote, "lucky." I think it's lucky when you loop that wire. You get there, you're right next to where the reconstituted segment is, and then you straighten out the wire, and boom, it goes luminal. You're just like, "Okay." You might drop and you're pretty much done with the case after a lot more steps.

(2) The Importance of CTOP Classification

[Dr. Sabeen Dhand]
We've all been there when you're doing these CTOs where you're trying the conventional technique, the wire is looped, and now all of a sudden, the loop is extending. When I'm saying loop, it's in the subintimal plane and it's extending past that point. That's where you start saying, "Okay, exactly." You want to come back where it's reconstituted. You have talked about CTOP plenty of times before. Is CTOP still something that you are-- the classification, is it something that you use on every single case?

[Dr. Jihad Mustapha]
Absolutely, Sabeen. If you really want to be doing the safest thing for the patient, which all of us do. We'll probably all do it subconsciously without knowing, even if we know the CTOP classification or we don't, every one of us probably think the same way. What is the safest way to reconstruct the CTO? If you have a type III CTOP which you have an antegrade convex cap, and retrograde-- sorry, distally will be concave.

It's going to be difficult to come from above and the wire get deflected left and right at the proximal portion. When you see the wire coming down and suddenly hitting something and goes left or right, you know you have a problem there. This is where you have to decide, should I stick with the wire catheter technique here because I'm going to go subintimal for sure, or do something else?

This is where the CTOP really helps. Then the other option would be if you have a nice convex CTO cap where the wire catheter will go right through it and when you get distally and the wire get deflected again, right or left, that's where you have to stop and think, how much do I want to mess with this vessel down here? Do I want to perforate it, dissect it, or should I go into alternative methods as well?

Alternative method would be using Outback and Pioneer, that's two methods that are known to be good and effective. I remember the shaft of the Outback, some of the shafts are 80 centimeters, some are a little longer. You have to be careful which one you pick if you pick it. That's an advice I would like to give everybody. Make sure you check the shaft.

(3) Re-Entry Devices vs. Pedal Access for CTOs

[Dr. Sabeen Dhand]
Something that I want to go into is, we haven't mentioned yet, but pedal access. I think every operator now who's doing CLI are pretty comfortable with pedal access and, in our experience, I would say in my practice, that five minutes that you're trying to do a conventional antegrade wire catheter technique, if it's not working, I think we, in my practice, go directly to pedal and start working that way, instead of going to devices that you mentioned Outback, Pioneer.

We'll talk about some more re-entry devices, but do you typically go directly to pedal then or are you more favoring these devices for a fempop lesion?

[Dr. Jihad Mustapha]
I have not used a re-entry device for many years now. In the past, we used them more, but then we started to compare, how long does it take, and the Outback for a while, if you remember, tip of it used to break when you go on the horn. They pulled it out, fixed it. The Elite now works well, and the Pioneer you can always find it. There's always short of it.

Since then, based on the complexity of our patients, if we don't actually recross, within a few minutes, nothing is going to change. We'll get pedal acess, and you take retrograde 0.18” wire catheter. The surprising thing Sabeen, is when you cross so quick, the distal cap I mean you're in a true lumen, and you cross is like, "What the heck. It took me two minutes to do this right now and I've been struggling up there for more than five minutes, usually."

You start to feel like, "Okay, next, I'm not going to do this." Now actually, if the CTOP classification is something complex, believing we, start with actually pedal access. Someone can criticize us for that, that's fine, it's appropriate because you don't know if you're going across from above. You should try from above first and then go with pedal access. What we've learned with that is, and we'll publish some of this data as well from the prime registry, when you do it from retrograde, and you cross the steel cap, you then find out your CTO is not actually as long as you thought, and then you find that you're in the true lumen more often than ever, actually, because of the IVUS.

We shifted a little bit now Sabeen, where long CTOs, we start with the pedal acess, come on up, cross the CTO cap all the way up as far as we can, and then we'll stop before re-entry and actually, if it just pops through, we'll finish it with TAMI technique. If not, we'll come from above and then do the flossing technique and then from there.

(4) Re-entry Devices

[Dr. Sabeen Dhand]
And then go and finish off the case, right. Where in that algorithm do re-entry devices fit your-- I'll be honest, we do a ton of CLI in my practice. My practice is mainly diabetics and I have a lot of tibial disease, but I have plenty of SFA-Pop disease but using pedal access, I have felt no need to take a re-entry device out because we tend to be able to cross it with a wire and catheter. I want to know for myself and for audiences, what re-entry devices are out there and why should I use them?

[Dr. Jihad Mustapha]
The most commonly available now, two devices that we're all familiar with are the Outback Elite and the Pioneer. There's actually some tips and tricks to them if you're going to use them. The Pioneer, when you've taken it up and over around the horn, you have to always respect it and I tend to use it with a 7 French sheath you can push it through a 6 French sheath is fine, and these they use a 7 French braided sheath because when you go around the horn, you have to actually rotate the needle angle of the Pioneer that is facing down.

Basically, it kind of rides the horn of the aorto-iliac junction, so you can advance it down and smoothly. Otherwise, actually, you will be looking up, so the vector of force will be going away from the contralateral iliac artery. With small rotation, you advance and take it down to where you need it to be and then when your get there, also, be patient because when you rotate in the Pioneer, you have to wait for the forest rotation to get there because the going around the horn, and many of us including me don't do that.

This is one check about the Pioneer. The other thing is please always remember to use a non-hydrophilic wire with it because if you use a hydrophilic wire, you know the consequences of that. That's another thing that's very important. The Outback is similar to the Pioneer. Make sure you always look at the different shafts that come in because you don't want to be going up and over and then you have an 80 centimeter shaft versus 135 and then you want to re-enter at the popliteal then you won't reach.

Again, when you're taking the IVUS catheter of the aortoiliac junction at the horn, the tips can break. For the Pioneer you can lose the value of the IVUS if you break it. For Outback, if the tip bends, then you can lose the functionality of it because it takes it away from the re-entry component or the lumen comes at a distance. These two things for them-- and besides these two, there's not that many out there that actually will give you the good outcome that these two can give you.

When you re-enter, make sure you're not too far in the adventitial space because then you have an angle re-entering and you don't want an angle to [crosstalk].

[Dr. Sabeen Dhand]
That's a good point. The angle can really mess things up. What are some other devices? I believe there's Reflow out there, what are some other ones?

[Dr. Jihad Mustapha]
There's devices that was used in PQ Bypass devices with Limb Flow, but these are not on the market yet. These are re-entered devices, and they'll be in the market soon. There is the Sting Ray which is-- if you're treated just subintimally when it would get back in the lumen and it's more effective when you use it in the tibials, popliteal. It's not very strong, kind of penetrating type of device because it's not a needle, it's a wire that comes out.

The last thing that we use, something called the Wingman, and the Wingman is made by a company called Reflow, and it's got a needle on it. It's 035, 018, and 014. The value of this device in our practice, it's actually cool because you can actually bend it, shape it, and then use it to-- so you don't have that 45-degree re-entry or whatever, you can actually enter it maybe 30 degrees if you want or 15 degrees based on the shape that you make.

[Dr. Sabeen Dhand]
It's designed for like to cross the CTO right? That's what the [crosstalk].

[Dr. Jihad Mustapha]
It's a CTO Catheter.

[Dr. Sabeen Dhand]
It basically centers you and then you can push through, but you've used it in a-- That's neat. You can bend it.

[Dr. Jihad Mustapha]
Yes, because if you shape it, it retain the shape that you put on it, but then with retrograde access and the ability to use two angled catheters, and two angled catheters as we put them next to each other and you start to rotate them back and forth like this, what they do is they break the cap and based on the CTOP analogy of the type of cap you're dealing with, it doesn't matter how complex the cap is, nothing actually crosses the complexity of the CTOP caths better than two catheters come from two different directions on it. They're both in the lumen and they just keep just shaving out--

[Dr. Sabeen Dhand]
I call it like battling of the wires and eventually-- to be honest, we barely even do a car-- it's very rare. I'll put a balloon up and try to make a space. I think, two wires and angled catheters that are lubed and they're going around whatever circumferential subintimal plane you're in, eventually, you're going to connect the two planes, you just have to work at it right?

[Dr. Jihad Mustapha]
We were very fortunate to be able to see under ultrasound. As you know we use ultrasound intra. You can see the catheters actually demolishing the cap and getting closer to each other and you can see sometimes one penetrating the other. If you ask me about the time it takes to do this, it's actually a lot shorter than anything else. Long CTOs right now, no matter how long they are, our time to cross them is less than 10 minutes.

It's not because we're good, it's because we use the technology that is available to us and allows us to see what we're doing and we use the CTOP. You have data, you have technology, all you have to do is tie the two together and then you can cross intraluminal a lot quicker.

(5) Re-entry Devices Below-the-Knee (BTK)

[Dr. Sabeen Dhand]
I have two questions for you now. You mentioned one is that you've used re-entry devices for the tibialis and I've usually just thought re-entry devices are for fempop. Have you used one of these devices in the setting of below-the-knee disease?

[Dr. Jihad Mustapha]
Yes, of course. The Outback more than anything else. Remember, Outback is bigger and you have to be careful when you use it and the Stingray, we use it more often. That was years ago before-- maybe six, seven years ago, but since then, since we started realize the ultrasound, the retrograde access, quite frankly, we stopped using any re-entry device since then.

Not because of anything against them. The re-entry device is great and if you're comfortable with them, you should use them. For us, we found alternative methods where, you're know you’re in the true lumen from retrograde and the wire that is subintimal from antegrade, just leave it where it is. The next thing is the retrograde wire just goes by in a true lumen and the next thing that you get it crossed-- There's no need to re-enter from subintimal into true lumen in a tibial because as you know, the data on there is really bad. It's poor outcomes.

(6) Re-Entry Devices with Long Subintimal Tracts

[Dr. Sabeen Dhand]
Exactly. My other question I was going to follow up on is about-- we talk about being subintimal and true lumen. You've mentioned it a lot. Obviously, when we're using re-entry devices or when we're doing these retrograde-antegrade techniques, a large portion of our CTO is going to be subintimal. Do you have any problem-- I mean, this has been debated many times and has been talked about, but do you have any problem with a long subintimal tract?

[Dr. Jihad Mustapha]
As you said, for the longest time they looked at, is there any value between putting a stent in a subintimal space versus in a true lumen in long CTO? The answer was no. That's actually stenting, that's not anything else. The RESILLIENCE study was one of the best studies that showed basically, if you got across subintimal and re-enter, you get a stent and get a good actually prepped vessel.

When a stent is placed, it's very well opposed. The sizing is one to one or 1.1 to one, and you get a good result of that. If you don't prep the vessel well, then subintimal recanalization with a stent may not be the best option.

[Dr. Sabeen Dhand]
I completely agree that a stent is needed in the subint[ama]. I've seen some people even in my own practice, some of my younger guys that have recan[alized], and then angioplasty, DCB, but you can see if you IVUS that, it's a freaking Martian landscape. That's not going to stay open even if it looks decently okay on angios. Stenting is very, very important.

One situation I found that I do use a re-entry device or at least try to, is a fempop CTO with a single vessel runoff being the peroneal. That one I think there is a very good argument to maybe try a re-entry rather than direct peroneal access, which is what we do too, but I think a re-entry might be better in that situation. What do you think?

[Dr. Jihad Mustapha]
I agree with you 100%. If you have a single vessel runoff and we can re-enter as far away from the peroneal as possible. Do it and do what you have to do and get out. Personally, right now, if I have that situation and I cross and the patient does not have any wounds, I tend to use either drug-coated balloons or drug-elluting stents in that fempop because the long-term patency if put a balloon in or any other, whatever your favorite is, I'm not going to actually mention many names, drug-elluting stents versus drug-coated balloons.

Based on how complex that lesion was, you can make a decision because now that you have a single vessel run after the foot and you give it a good, nice, juicy inflow with high blood volume, you're know you’re going to have a good long-term patency with drug-elluting technology. On the other hand, same scenario that you just mentioned, we do what we call a Schmitd access technique where we access an occluded artery, especially the PT, and we go through it on the ultrasound and we cross.

You'd be surprised actually how often we cross very quick and then go up and cross the distal cap and then reconnect together. The nice thing about that is, again, to our surprise, we find ourselves in a true lumen in SFA, popliteal. We can see the wire on IVUS in the subintimal space where it went into subintimal space, we just pull it back to where the retrograded wire is in the true lumen and then connected the two together and floss and then treat.

I'm not expecting everyone to do this, but using ultrasound to be accessed in an occluded artery, especially the posterior tibial is really a good idea. You take a V18, you rotate it as you go in, and if you don't feel comfortable with that. You don't have to do it, but it's really not as bad as you think. Once the wire goes up a little more, it starts to face some calcium, it loosens itself, then you do Janali technique where you just going to let it loop and rotate it.

That wire propels itself forward and it just finds its way all the way up to the pop and to the CTO and then keeps, if you have momentum with it, it just keeps going straight. We do that technique as well. Your point about single vessel runout using re-entry devices, that should be in everyone's mind. What I just mentioned right now, that would be like a resort if you want to resort to something else besides re-entry.

[Dr. Sabeen Dhand]
I personally have not used an occluded vessel that often. I've done it once or twice where it's nice though, if you're not going to bag an artery, it's already occluded. You can't do anything bad to it. My concern is that when you're in that occluded vessel and then you want to re-enter into the normal vessel, you want to go to true lumen before you're going to attack the actual CTO that you're going to go for, that you can get stuck in that subintimal plane from below.

I don't know how often that's happened to you. You've done a lot more than I have, but I could see myself getting stuck in, then in the pop you're still subintimal now you're just subintimal all the way and I don't know.

[Dr. Jihad Mustapha]
Beautiful thing about it Sabeen is-- and number one, I really commend you for bringing that up. That's a very good point. You have a single vessel runoff, you have a popliteal that is intact. The last thing you want to do is actually do something bad to the popliteal, TFT, peroneal. I agree with you 100%.

[Dr. Jihad Mustapha]
The beautiful thing about having a Janali technique retrograde, even if you go subintimal and you go up, it does not affect the lumen of the popliteal because of the flow. The flow tacks up anything that-- if you dissect, for instance, it will tack it up. We've done probably thousands of these [laughs] between me and Fadi. We've done a lot of it.

The reason we do it is not to actually avoid using a re-entry device because we actually gain more lumen from the Popliteal, SFA and then that vessel that we accessed was occluded, guess what? We reverse access at the end of the case and then reanalyze it into the plantars so none of the patients have a new tibial artery into the tibioperoneal. We do this only if we feel there's a need for it and we use 5 French so much to do most of our work.

[Dr. Sabeen Dhand]
I started using more, larger access in the tibials after seeing all of your guys' good work. I still, overall in the majority I'm keeping, a bareback Quick-Cross catheter or whatnot in the tibial going up and doing the majority of work from above. It has definitely helped to be able to use 5 French catheters and everything from below, especially for complex trifurcation or popliteal work. Absolutely.

[Dr. Jihad Mustapha]
I just want to add one more thing, Sabeen. I want to hopefully not misunderstand that what we're doing is aggressive. We don't push anything. When you rotate the general wire loop, you actually just basically rotate it clockwise or counter clockwise and it will propel itself. If there's a problem, but if it stops or it starts to look different directions, we stop and I reassess. We have not had a major issue with this.

[Dr. Sabeen Dhand]
Does your Janali wire ever break?

[Dr. Jihad Mustapha]
Of course. Absolutely. Every wire that we use breaks. Not every day, I mean. Not on regular patients. There isn't a wire that we use that doesn't break. When it breaks, 100% of the time it's gone subintimal and it broke in the subintimal space.

[Dr. Sabeen Dhand]
It doesn't matter, almost.

[Dr. Jihad Mustapha]
The question that I get all the time is, do you want to go snare? No. It's a good place [crosstalk].

[Dr. Sabeen Dhand]
Why? You're going to get rid of that subintimal plane anyways?

[Dr. Jihad Mustapha]
There's no lumen to begin with, and when you leave it in a subintimal space and the catheter behind it, you get a new wire and now that subintimal space is glued with that wire that broke off, and then you just go by it, you pass it in the in the true lumen and you go up. I'm simplifying it, but it definitely-- no matter how many you do of these when a wire breaks off, Sabeen, you always feel bad that not following-- You try to get it out somehow, knowing that it’s in the subintimal space and we use ultrasound and IVUS to double-check that. As doctors, we all think alike. We don't like to see anything out of the ordinary.

[Dr. Sabeen Dhand]
Obviously. Don't want to leave anything there, but it looks like our discussion's pretty clear that these complex, whether it's fempop or tibial occlusions, I mean, pedal access and using conventional techniques and some other advanced techniques like Janali and other things can really, really revasc these lesions whether it's sub-intimal or true lumen. We are fortunate in this day and age to have re-entry devices for some special situations. One we mentioned, single vessel runoff.

(7) Re-Entry Devices for Iliac Occlusions at the Iliac Bifurcation

[Dr. Sabeen Dhand]
Something else that came to my mind was, I think, there's utility in an iliac occlusion at the bifurcation. I think Outback or Pioneer tends to be my first choice in those. If it's a flush common iliac occlusion, do you feel the same way?

[Dr. Jihad Mustapha]
Oh, absolutely. We almost never re-enter without the Pioneer because sometimes you get fooled by the lumen that you see and you think you’re just sub-intimal. Then you IVUS and you find yourself way far out and that's when you--

[Dr. Sabeen Dhand]
Extravascular.

[Dr. Jihad Mustapha]
Yes, especially close to the carina. We always IVUS first and then we see the distance to the lumen and then reassess. Pioneer is actually what we use primarily in the iliac junction, especially if we're close to the carina. As you know, if you perforate in the area next to the iliac junction carina area, trying to control that is pretty complex and you're not always as successful as fast as you want.

When we get to that point with IVUS, we measure, and then we use the Outback, and then with that, definitely we enter with it, and the results are usually great. I'm glad that you brought that up because that's a very good point.

[Dr. Sabeen Dhand]
Yes, it came to my mind. Then also I was thinking, and we mentioned this briefly before, is, are there other devices to help us cross the CTO, and maybe we could remain true lumen. You mentioned Wingman. I've never used that before, but from what I remember is that it centers you and you can try to just break the cap in the center. Has that been your experience?

[Dr. Jihad Mustapha]
You know what, the Wingman is something that we used to think about at the 100th hour. You spend an hour trying to cross, and then you get the Wingman, and then you cross in 60 seconds and you're always-- you just want to hit yourself, man. Why didn't I do it sooner? The benefit of the Wingman is it's just designed very nicely. People always think, oh there's a needle in there.

Well, believe it or not, Sabeen, when you start escalating the wire that you're using and the grand tip of that wire, if you measure it like head to head between the Wingman because we have a wet lab here, so we're always testing devices. If you use high gram tip wire versus a 018 Wingman, the high-gram tip wire can actually have a much higher penetration through the vessel wall than the Wingman.

[Dr. Sabeen Dhand]
Interesting.
[Dr. Jihad Mustapha]
We use the Wingman now immediately if we have a proximal CTO cap, ostial SFA cap, CTO, or distal popliteal. We go from retrograde with it. When you start to rotate it, and it engages the cap, it stays in the cap. It's not like it changes its vector. We used to wait until, I don't know, half an hour, 45 minutes, and then okay, let’s use the Wingman.

Now, if the wire cap doesn't work and we haven't crossed the proximal cap, we'll go straight to 035 Wingman, antegrade, and we tend to almost always cross. We have not failed with it yet, the 035 antegrade. I'm sure we will some day --. Then, I just would like to say that we use ultrasound, so it's unfair for me to say that. We have not failed because ultrasound tells us exactly where we are and what we need to do but the device is phenomenal.

As you rotate it, they have a 90-centimeter shaft so you have complete control and as you rotate it you can see the needle tip penetrating the cap, then you have a wire to support it. Once we cross the cap, the rest is easy. It's an advice to those that want to actually venture into a controlled setting because safety is first. If you feel comfortable with it, one of the things you can do if you don't have an ultrasound, you do AP and ipsilateral oblique views. If actually the Wingman is still in the same place, you're safe. You can continue.

[Dr. Sabeen Dhand]
Got it. Just to clarify, in your algorithm when that comes up because by the time I'm working on these lesions and I'm already having pedal access retrograde, I'm probably sub-intimal on both sides, so I don't really know when-- I don't think the Wingman would be beneficial at that point when you're already committed. Is that correct?

[Dr. Jihad Mustapha]
Correct. That's a mistake we made for a long time where we used the Wingman later. That was--

[Dr. Sabeen Dhand]
You can't. Then it doesn't make sense. You want to use it to cross the cap centrally.

[Dr. Jihad Mustapha]
Yes. Now we try to cross and we couldn't cross. If you can't cross with a high-gram tip wire and a catheter behind it based on the studies that were done by Asahi and other companies. You're talking about 100, 120, up to 160 grams, it depends on what you're using. If you can't cross with that, it's time to shift to something else. The benefit of the Wingman, if you actually watch how it rotates, the tip of it, it rotates almost in a circumferential fashion. People think it just rotates with its OD.

Actually, it gives you double the OD of the needle. When you go back with something else, you have created a dot and leg channel so you can actually advance the loads or other things or catheters behind it. That's the value of it, but if you committed to dual subintimal spaces, within the past we didn't have good success.

That's great. No, it's good. I think there's always devices coming out and it's helping us. Sometimes it's diluting and we don't know, we have too much to use and it's hard to decide, but it's definitely nice to hear from your experience and from others to see which situations and everything works because as your volume goes higher and higher, you start seeing more complexity and you start dealing with more complex lesions.

(8) Future Devices

[Dr. Sabeen Dhand]
Do you see anything on the horizon in the future for other devices to help crossing large occlusions? Do you think they're going to be so easy to do five years from now? Is there going to be some evolutionary, revolutionary stuff?

[Dr. Jihad Mustapha]
There's a few actually that are coming out. There's one from Europe. It's a CTO device and a re-entry device simultaneously together. There's another device being worked at by Reflow. That's also a device that's actually CTO crossing and a re-entry device. Companies are starting to get smart. They're going to give you not just a CTO crossing device, but also if it fails, it becomes a re-entry device. That's kind of cool.

[Dr. Sabeen Dhand]
That's cool. Very cool.

[Dr. Jihad Mustapha]
If you're there, and if you're stuck, then you pull back. It's almost like a one-way valve, and then you advance your needle, and then you're in re-entry mode now. Once you go into re-entry mode, you can't go back into the CTO crossing mode. Which is fine because you may have crossed [crosstalk].

[Dr. Sabeen Dhand]
Maybe you might enter into the occlusion, and then you need some more stuff. That's very cool. That's one of the reasons I think all of us love endovascular work. There's just technology left and right, all sorts, and CLI, and neuro, everything. It's just so cool to be a part of this.

[Dr. Jihad Mustapha]
The last one that is being worked on right now, this one is really cool. When you un-sheath it, it has a spring system or a stent that takes the shape of the artery, so hugs the artery and basically, it pushes the re-entry-- It's a CTO crossing device first but if you want to re-enter, you unsheathe that and that releases the crescent stent and that pushes the re-entry device, which is a CTO device now, closer to the artery.

Actually, the distance to travel to re-enter is much shorter than any other devices. That one is-- I'm not sure how far it is. The company is working on it is-- they come and talk to us about it and then we will try it, actually, in cadavers. That one is going to be a cool one when it comes out. The one from Reflow is really cool. Actually, all of them are really cool because I like how everyone is thinking like we're thinking.

We have a CTO device, trying to cross, we didn't. We have a re-entry in the same device. You don't have to exchange, no new device, cost is down. Cost-effective methods.

[Dr. Sabeen Dhand]
Well, I think, Jihad, you've been doing some amazing work. It's so nice to have you back on after so long. It's really helpful for the entire CLI, CTLI community to learn from what you, Fadi, and all of ACV, what you guys are doing.

[Dr. Jihad Mustapha]
Appreciate it.

[Dr. Sabeen Dhand]
I really commend you guys for driving this field on. I learned so much from you and I know everyone else does so I just wanted to thank you. If you have any parting words of wisdom for our listeners, you guys always have such good things to say.

[Dr. Jihad Mustapha]
I do actually have a couple of things to say. The CTO crossing is the most important part of treating a patient with CLI. In the vascular revascularization really depends whether you get flow to the target organ, the foot. If you don't get flow to the foot, you really didn't succeed, and no matter what you do. I just want to mention few catheters coming out.

We still have some catheters that help CTO crossing. Actually, the catheter itself, the catheters are coming out from different companies right now. They have CTO modalities. They're not CTO catheters, but they're good for support. We still have one, and a company called Asahi. This kind of things would like to leave our colleagues with to think about these devices because when we got them, and we use them was like, "Wow."

Reflow, and Asahi is a company now they have theirs out. Other two, there's 035, 018 only, at this point by Terumo and Asahi. The 014 is on the way. Kudos to these companies. By the way, there is no connection with them. I just really appreciate the fact that they give us what we need. There's not much to use in CTO crossing of the tibial pedal arteries, so I always appreciate the effort they put into it.

As you know, it's complex, and you don't want to mess the target organ vessels. That's the most important thing. Look for these catheters, if you're working in the tibials and tibial pedals because I'd like to say, a couple of papers were published the CTOP showed 67% conversion from antegrade to retrograde. And retrograde was more successful. Another paper published that the highest mortality rate for patients with CLI is the CTO that's present at the distal tibials or tibial pedal arteries. When you see that CTO over there, you got to go out there and open it. I'd leave you with that. The highest mortality rate with CLI patients are patients that have a CTO present at distal tibials or tibial pedal arteries. It's published in a CLI journal. [crosstalk].

[Dr. Sabeen Dhand]
That's great. Those are the hard ones to-- those are hard. If it's distal AT/DP/CTL, they are very hard. That's great that we're having these devices to come and help us and all the techniques like you mentioned Janali, being more, opening our methods for pedal and everything. I think it's been a really good time to be treating endovascular work.

[Dr. Jihad Mustapha]
Absolutely, it's really helpful to show that there's hope for patients that don't have hope. I'm talking to you about patients that come to us with an occlusion in the SFA and then there's no reconstitution. These are the ones that are worth discussing one day.

[Dr. Sabeen Dhand]
Awesome. Well, Jihad, thank you so much. I really appreciate you coming on. There's a lot of info and really, I think we have a lot more to discuss these days and look forward to seeing you and having you on again. Thank you, Jihad.

[Dr. Jihad Mustapha]
It's been an honor, my friend. I'm always honored and I love BackTable. I look forward to being a guest again in the future.

[Dr. Sabeen Dhand]
Thank you.

Podcast Contributors

Dr. Jihad Mustapha

Dr. Jihad Mustapha is a practicing Interventional Cardiologist and CEO at Advanced Cardiac & Vascular Centers for Amputation Prevention in Michigan.

Dr. Sabeen Dhand

Dr. Sabeen Dhand is a practicing interventional radiologist with PIH Health in Los Angeles.

Cite This Podcast

BackTable, LLC (Producer). (2023, March 27). Ep. 305 – Tools for Crossing Challenging CTOs [Audio podcast]. Retrieved from https://www.backtable.com

Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.