Peripheral Chronic Total Occlusion (CTO) Crossing Devices: How do we choose the right device?

Anand Prasad, MD, FACC, FSCAI
Editorial Board Member Journal of Invasive Cardiology
University of Texas Health Science Center San Antonio
San Antonio, Texas

Chronic total occlusions (CTOs) remain a challenging lesion subset in the peripheral circulation. For years, CTOs – particularly long or heavily calcified have been the domain of surgeons for distal bypass. Although, surgery is still an option in some patients, the explosion of crossing technologies and atherectomy devices has allowed endovascular specialists to tackle these lesions with greater success rates. With the multitude of crossing technologies available (see Table), it is difficult to make sense of which device should be used on which lesion or patient. This problem is compounded by the lack of independent data and specifically by the lack of randomized data.
Some common considerations for device selection include lesion length, degree of calcification, proximal and distal stump characteristics, re-entry zones, and planned therapy (atherectomy versus angioplasty alone). More practically however, few if any labs have all devices therefore developing a comfort level with 2-3 is a reasonable approach. In addition, cost is often overlooked but needs to be considered as use of the majority of crossing devices results in no additional reimbursement for the procedure. The short answer is that there is likely no “right device” for all lesions or operators. Gauging the effectiveness of specific devices will require data from real-world operators and not just from industry sponsored registries or post-marketing studies.

To read Dr. Prasad’s current article in this month’s JIC, visit Recanalization of Popliteal and Infrapopliteal Chronic Total Occlusions Using Viance and CrossBoss Crossing Catheters: A Multicenter Experience From the XLPAD Registry.

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