Technical perspectives in the management of complex infrainguinal arterial chronic total occlusions.

The prevalence and incidence of peripheral arterial disease have been increasing in the general population. Although limited data are available on the epidemiology of chronic limb-threatening ischemia, it likely represents <10% of all patients with peripheral arterial disease. In the general population, its overall prevalence has been 0.74%. This specific subgroup of patients can have severe disease presentations. Their symptoms often correlate with a specific infrainguinal morphologic pattern known as chronic total occlusion (CTO). CTO will often be difficult to cross in a standard endovascular fashion. In previous years, several techniques have been developed to overcome the limitations of standard antegrade endoluminal or subintimal approaches, if these approaches fail. We have described the advanced techniques, including subintimal techniques, such as crush balloon, parallel wire, SAFARI (subintimal arterial flossing with antegrade and retrograde intervention), and double-balloon techniques, in detail. Furthermore, we have described a homemade reentry device, which can be used to provide access to the distal true lumen in extreme, uncrossable cases. Retrograde approaches comprise several techniques developed from interventional cardiology techniques. Finally, we have described transcollateral and pedal-plantar loop techniques in detail. These techniques allow endovascular surgeons to successfully encounter even complex anatomies, which will be present in ∼80% of all CTOs. In the present report, we have reviewed all these advanced techniques, correlated the effectiveness of each with the proximal and distal cap morphologic features, and discussed the economic consequences of the endovascular approach considering the costs vs the disease progression and the materials used during the procedures. Effective use of the advanced techniques we have described is of paramount importance because only 20% of patients will have a CTO that is crossable using standard techniques. Thus, the use of these techniques can help endovascular surgeons increase their success for patients with complex anatomic patterns. Furthermore, the possibility of treating these CTOs using only guidewires and catheters will reduce the costs of the procedures. However, their use in clinical practice still must be standardized. [ABSTRACT FROM AUTHOR]