Recanalization of Femoropopliteal Chronic Total Occlusions Using the ENABLER-P Balloon Catheter System

Primary Use of the TruePath Crossing Device for Infrainguinal Chronic Total Occlusions With Intravascular Ultrasound Evaluation

PURPOSE

To evaluate the use of the TruePath crossing device as the primary recanalization tool for infrainguinal chronic total occlusions (CTO).

METHODS

A retrospective analysis was conducted of 50 patients (mean age 75 years; 26 men) with 55 infrainguinal CTOs treated with the TruePath between March 2017 and September 2017 at a single center. The mean occlusion length was 138±55 mm, and femoropopliteal lesions accounted for 65% of the 55 lesions. The primary outcome measure was CTO crossing using the TruePath alone; secondary outcomes were assisted success (>50% lumen gain using the TruePath), device-related complications, and intraluminal crossing evaluated by intravascular ultrasound (IVUS).

RESULTS

Complete success was achieved in 33 (60%) of 55 lesions having a mean occlusion length of 145±72 mm. Among these, the true lumen crossing rate was 97% according to IVUS evaluation. Assisted success was achieved in 15 (68%) of the 22 failures. Complete/assisted success, in which the TruePath was thought to have contributed to CTO crossing, was attained in 48 (87%) of the 55 lesions. Three (5.5%) complications were observed: a perforation, an access-site hematoma, and acute occlusion; only the perforation was device related (1.8%). Multivariate analysis showed PACCS grade 4 (odds ratio 4.5, 95% confidence interval 1.33 to 15.5, p=0.02) was an independent predictor of TruePath failure.

CONCLUSION

Primary use of the TruePath crossing device for infrainguinal CTOs demonstrated a satisfactory complete success rate and a high rate of IVUS-documented intraluminal crossing with few device-related complications. Severe calcification is an independent predictor of TruePath failure.

Technique of percutaneous direct needle puncture of calcified plaque in the superficial femoral artery or tibial artery to facilitate balloon catheter passage and balloon dilation of calcified lesions

Heavy calcified arterial lesions are challenging to endovascular treatment. Even if a guide wire passes the lesion, calcified plaque can inhibit passage or dilation of the balloon catheter. We developed a novel technique of percutaneous direct needle puncture of calcified plaque (PIERCE) to allow subsequent passage and dilation of the balloon. PIERCE was performed in three patients with superficial femoral artery (SFA) lesions and one patient with a tibial artery lesion. In all four cases, balloon passage and lesion dilatation were achieved. Minor hemorrhage from the punctured site occurred in two patients with SFA lesions, which resolved with stent placement.

Intraluminal crossing of near-impenetrable occlusions by balloon-assisted battering ram technique

PURPOSE

Subintimal crossing of total occlusions and acquiring reentry into the true lumen may be hazardous in highly calcified lesions, with or without the use of expensive reentry devices. Even when desirable, intraluminal crossing may not be feasible, because the guidewire tends to follow a path of least resistance between the intimal plaque and the adventitia.

TECHNIQUE

A standard percutaneous transluminal angioplasty balloon is positioned just above the proximal cap of the occlusion and insufflated to 6 atmosphere. The balloon is used (1) to increase guidewire support close to the lesion and (2) for centralization purposes (limiting lateral movement of the guidewire). The ultra stiff back end of a regular guidewire can then be used to target the center of the cap while repeatedly pounding against it until it breaches.

CONCLUSIONS

The balloon-assisted battering ram technique may be attempted if intraluminal crossing is warranted before resorting to other complicated, expensive devices.