1. Peripheral Artery Advanced SFA-CTO Techniques in the
CTO Forum
February 21, 2010
Nelson Lim Bernardo, MD Washington Hospital Center

2. Nelson L. Bernardo, MD DISCLOSURES Honoraria
The Medicines Company, Cordis, a Johnson & Johnson company, Bristol-Myers Squibb/Sanofi Pharmaceuticals Partnership

3. 50% in patients with intermittent claudication
Nadal et al. Techniques in Vascular and Interventional Radiology ;7: Chronic Total Occlusions (CTOs)
CTOs of the superficial femoral artery (SFA) occur in up to 50% of patients presenting with symptoms of peripheral arterial disease (PAD).
These patients often have coexistent cardiovascular and cerebrovascular disease which increases the 5-year mortality rate by:
50% in patients with intermittent claudication
60%-70% in patients with CLI (critical limb ischemia)

4. CTO: Treatment options
Surgical revascularization
Percutaneous endovascular intervention (PEI)

5. CTO: Treatment options
Surgical revascularization
Femoro-Popliteal artery bypass
Long/Total occlusions
Unfavorable anatomy
Patient’s preference
Percutaneous endovascular intervention (PEI)

6. CTO: Treatment options
Surgical revascularization
Femoro-Popliteal artery bypass
Long/Total occlusions
Unfavorable anatomy
Patient’s preference
Percutaneous endovascular intervention (PEI)
Initial approach to the treatment of PAD and CTO
Cognizant of the “pitfalls”
Challenge: Cross the CTO safely and efficiently

7. Opening CTO: Percutaneous Approach
Percutaneous Endovascular Intervention (PEI) as the initial approach to the treatment of PAD and CTO - “Nothing to lose”
Challenge: Cross the CTO safely and efficiently
Both for the patient and operator
Appropriate use of devices & drugs
Do not ‘burn’ the surgical option

8. Tackling CTO: Percutaneous Endovascular Intervention
Cross or ‘break’ the proximal and distal caps of the totally occluded segment
Cross with the guidewire - ‘loop-wire’ technique
Subintimal angioplasty - percutaneous intentional extra luminal recanalization (PIER)
Excimer laser - ‘step-by-step’ technique
Frontrunner XP CTO catheter - ‘blunt’ dissection
Crosser High-frequency ultrasound - ‘hammer-through’
Safe-cross (with OCR) - ‘guide-through’
Tornus catheter - ‘screw-through’
CiTop guidewire system - ‘inch-through’

9. Tackling CTO: PEI Options
CTO devices - ‘niche’ role; improves acute success.
There is ‘paucity’ of good data to favor any particular treatment modality.
We have more “toys” in the Peripheral lab vs. Coronary lab.
Improved ‘acute’ outcome ≠ ‘chronic’ long term patency.

10. CTO: Recanalization pitfalls
Unsuccessful procedure ~ 20%
Inability to re-enter the ‘true’ lumen distally after going through a subintimal route (of the occluded segment)

11. CTO: Recanalization pitfalls
Unsuccessful procedure ~ 20%
Inability to re-enter the ‘true’ lumen distally after going through a subintimal route (of the occluded segment)
Inability to identify and cannulate the “flush” occluded superficial femoral arteries that show no residual “ostial stumps” angiographically

12. CTO: Recanalization pitfalls
Unsuccessful procedure ~ 20%
Inability to re-enter the ‘true’ lumen distally after going through a subintimal route (of the occluded segment)
Inability to identify and cannulate the “flush” occluded superficial femoral arteries that show no residual “ostial stumps” angiographically
‘Burning’ the surgical revascularization option
Distal extension of the dissection/subintimal plane

13. Duplex Ultrasound
Duplex ultrasound has long proven to be a valuable tool for guidance in a variety of medical interventions.
As of late, duplex ultrasound has shown its utility in providing imaging assistance during balloon angioplasty and stent implantation in the peripheral artery.
Valuable in patients with impaired renal function.

14. Angiogram vs. Duplex Ultrasound
Visualization of any structure on angiography is totally dependent on blood flow.
Total occlusion = NO flow = NO images
Duplex Ultrasound:
Ultrasound - shows the structure of the vessel
Doppler - shows the movement of red blood cells
Even in the absence of blood flow, i.e. totally occluded vessel which can not be visualized on angiography, ultrasound scanning can still provide images of the vessel (structure of the vessel wall).

15. Right SFA “flush” occluded
AH: Lifestyle limiting claudication
66 y.o. WM with PAD and recent worsening of symptoms. “Failed” Cilostazol.
(+) CAD (+) HTN. (+) DM. (+) lipids.
(+) unilateral RAS – Med Tx. Asymptomatic right CAS.
(+) smoker.
ABI: Right = Left = 0.75
Right SFA “flush” occluded

16. AH: Right SFA – Ostial “flush” total occlusion
Right SFA - distal segment
Right SFA - proximal segment

17. Right SFA - flush occlusion
CTO: Ostial “flush” occlusion
Right SFA - flush occlusion

18. Right SFA - flush occlusion
CTO: Ostial “flush” occlusion
Dilemma:
Where is the ostium of the occluded SFA?
PEI Approaches:
“Mirror image” - Look at the location of the ostium of the contralateral SFA
Retrograde approach - access via popliteal artery
Right SFA - flush occlusion

19. CTO: Ostial “flush” occlusion
Right SFA - ostium

20. CTO: Ostial “flush” occlusion
Ultrasound - Right CFA
Right SFA - ostium

21. CTO: Recanalization under US guidance
“Breaking” of proximal ‘CTO cap’
using the Frontrunner CTO catheter
under ultrasound guidancs
Ultrasound - Right CFA

22. CTO: Recanalization under US guidance
Frontrunner CTO catheter
“Breaking” of proximal ‘CTO cap’
using the Frontrunner CTO catheter
under ultrasound guidancs

23. CTO: Recanalization under US guidance
“Breaking” of proximal ‘CTO cap’
using the Frontrunner CTO catheter
under ultrasound guidancs

24. Right SFA - successful crossing
CTO: Crossing of ostial “flush” occlusion
Right SFA - successful crossing

25. Right SFA - flush occlusion
CTO: Balloon angioplasty
Right SFA - flush occlusion

26. Right SFA - Pre-treatment
CTO: Successful intervention
Right SFA - Pre-treatment

27. CTO: Successful intervention
Right BTK
Right SFA - Post-PEI
Right Foot

28. Duplex Ultrasound Guidance in CTO
Allows direct visualization of ‘occluded’ vessel
Guide catheter placement and wire/device access into “flush” occluded artery
Real time anatomical information while cannulating the occluded vessel
Verify that the wire/device is tracking intraluminally
Avoids potential catastrophic complications
Perforation - vs ‘blindly’ advancing guidewire/device
Subintimal plane/Spiral dissection

29. Duplex Ultrasound Guidance: Tools
Ultrasound imaging
Expanded and important role of the RVT
“Blind spot” at the Hunter’s adductor canal
Frontrunner CTO device
Sonographically “brighter” vs guidewire
Shapeable tip allows directionality
“Breaks” the proximal ‘cap’ of the CTO

30. RP: Recurrent resting pain
59 y.o. WM s/p multiple right L.E. revascularization procedures, with recurrent resting claudication.
s/p 3 arterial bypass of the right lower extremity; the last one in 2002 using a venous conduit.
Duplex: Occluded SFA + grafts, reconstitute BTK.
(+) HTN. (+) DM. (+) lipids.
AB: Right = Left = 0.56
Right SFA - Proximal

31. RP: Recurrent resting pain
Which “knob”
Is this ??
Right SFA - Ostium

32. RP: Recurrent resting pain
Which “knob”
Is this ??
AP View
LAO View
Right SFA - Ostium

33. RP: Right SFA
Right SFA - Ostium
Right SFA - Distal

34. RP: Critical limb ischemia
Right BTK arteries
Right SFA - Distal

35. RP: Critical limb ischemia
BTK T-P
Considerations:
Which one to recanalize – SFA vs graft
Where is the knob of the “native” SFA or grafts ?
Where is the distal anastomosis of each bypass graft?
SFA
Popliteal
Foot

36. RP: PEI of right L.E. CLI
Right SFA - Ostium

37. RP: Duplex scan to access “knob”
Right SFA - Ostium

38. CTO device “crossing” SFA stump
RP: Duplex scan to access SFA “knob”
CTO device “crossing” SFA stump

39. CTO device crossing “stump”
RP: PEI using duplex guidance
CTO device crossing “stump”

40. RP: Successful recanalization to BTK
Right peroneal artery

41. RP: Successful PEI of CLI
Right SFA – Post
Right BTK – Post

42. RP: Successful PEI of CLI
Right Plantar – Post
Right BTK – Post

43. Duplex Ultrasound Guidance in CTO
Allows direct visualization of ‘occluded’ vessel
Guide catheter placement and wire/device access into “flush” occluded artery
Real time anatomical information while cannulating the occluded vessel
Verify that the wire/device is tracking intraluminally
In-situ saphenous graft – ensure that the guidewire has not ‘tracked-off’ into side branches
Avoids potential catastrophic complications
Perforation - vs ‘blindly’ advancing guidewire/device
Subintimal plane/Spiral dissection

44. WHC Experience: SFA CTO and US Guidance
Single center experience, consecutive patients with CTO
2007
2008
2009
No. of CTO
158
130
159
“Flush” Occlusion
4 (2.5%)
7 (5.4%)
6 (3.8%)
Re-entry Device
31 (19.6%)
30 (23.1%)
27 (16.9%)
Procedural Success
98.7%
98.4%
100%
2o Success
99.2%
3o Success
Complications:
Perforations, etc. = 0

45. Conclusions:
This adjunctive imaging modality further improves our success in the ‘recanalization’ of chronic total occlusions involving the femoro-popliteal artery.
Duplex ultrasound still cannot replace contrast angiography but used in conjunction provides an additional tool to ensure the best outcome in patients undergoing percutaneous endovascular intervention.
Proper training and appropriate case selection are critical to optimize outcomes & minimize complications.

46. Thank you. Have a Good Day!
On the road to Mount Everest
‘Touching the Bells’