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

2. 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.

3. 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Traditional surgical techniques have been replaced by minimally invasive procedures

4. 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

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

6. 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

7. 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

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

9. Access
Contralateral
Ipsilateral Antegrade Retrograde Popliteal Tibial

10. Difficult Anatomy Flush occlusions Heavily calcified Long occlusions
Popliteal involvement

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

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

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

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

15. Crosser

16. TruePath

17. Excimer Laser
PELA (Peripheral Excimer Laser Angioplasty)

18. Debulking First
Excimer Laser

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

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

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

22. Bilateral Occlusions

23. Large Collateral

24. Heavily Calcified

25. Heavily Calcified

26. Retrograde Access

27. Popliteal and Distal Occlusion

28. Distal Popliteal Occlusion

29. Perforation

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