Crossing SFA-Popliteal Artery CTO’s Tyrone J. Collins, MD, FSCAI, FACC, FAHA John Ochsner Heart and Vascular Insititute New Orleans, LA

I/we have no real or apparent conflicts of interest to report. Tyrone J. Collins, MD I/we have no real or apparent conflicts of interest to report.

Background PAD affects 12-14% of the general population The treatment of patients with peripheral vascular disease has undergone impressive changes There has been an explosive development of endovascular techniques and devices Traditional surgical techniques have been replaced by minimally invasive procedures

PAD Marketplace and Devices Underpenetrated compared to coronary Device advances are expanding the patients that can be treated Products designed to improve durability and safety Reduce need for surgery Reduce rate of amputation in critical limb ischemia

Problems with PAD Therapy Lack large randomized trials comparing newer devices to PTA and surgery No consensus of technology superiority

Superficial Femoral Artery (SFA) and Popliteal Artery 60% of lower extremity occlusions and > ½ of all endovascular procedures Often diffuse, calcified and large plaque burden Restenosis is an issue Lesions around knee subject to mechanical forces that increase risk of stent compromise

Femoropopliteal Treatment Endovascular Treatment of Choice TASC A Single stenoses ≤ 10 cm Single occlusion ≤ 5 cm Endovascular Treatment Preferred TASC B & C Multiple lesions ≤ 5cm Single lesion ≤ 15 cm Lesions without tibial inflow Surgical Treatment of Choice TASC D Multiple lesions ≥ 15cm Recurrent lesion after 2 interventions

CTO’s Have to cross and re-enter Procedure safe with few complications Similar to coronary intervention Effectiveness of planned therapy must be considered

Access Contralateral Ipsilateral Antegrade Retrograde Popliteal Tibial

Difficult Anatomy Flush occlusions Heavily calcified Long occlusions Popliteal involvement

CTO’s 0.014 in. wire and catheter 0.035 in. guidewire and catheter Laser Frontrunner Crosser Truepath Reentry devices

Frontrunner®XP CTO Catheter Blunt micro- dissection Creates lumen for the wire

Outback®LTD Re-Entry Catheter Redirects wire to true lumen Visible markers

Pioneer Catheter Re-entry device that utilizes IVUS Wire redirected into true lumen

Crosser

TruePath

Excimer Laser PELA (Peripheral Excimer Laser Angioplasty)

Debulking First Excimer Laser

Subintimal technique Hydrophilic guide wire Catheter Pass the occlusion and re-enter the lumen distally Cannot use for all lesions

CTO’s Some of the most challenging cases Require more time Higher risk of complications Patience Equipment requirements Necessary skills

Dissections Unavoidable with subintimal technique Try to redirect wire May need retrograde approach May have to stage intervention

Bilateral Occlusions

Large Collateral

Heavily Calcified

Heavily Calcified

Retrograde Access

Popliteal and Distal Occlusion

Distal Popliteal Occlusion

Perforation

Conclusions Most SFA-Popliteal occlusions can be treated with a endovascular technique Choose patients carefully Appropriate equipment and technique(s) Consider the alternatives