Comparative Assessment of Guidewire and Microcatheter vs a Crossing Device–Based Strategy to Traverse Infrainguinal Peripheral Artery Chronic Total Occlusions

Subhash Banerjee, MD, Karan Sarode, MA, Apurva Patel, MD, Atif Mohammad, MD, Roosha Parikh, MD, Ehrin J. Armstrong, MD, Shirling Tsai, MD, Nicolas W. Shammas, MD, and Emmanouil S. Brilakis, MD, PhD

Purpose: To compare success rates of a guidewire and microcatheter strategy vs the use of specialized crossing devices to traverse infrainguinal peripheral artery chronic total occlusions (CTOs).

Methods: For this analysis, data on 438 consecutive infrainguinal CTO interventions in 438 patients (mean age 63.2 years; 402 men) performed between August 2006 and May 2014 were extracted from the multicenter Excellence in Peripheral Artery Disease (XLPAD) database (; identifier NCT01904851). Primary technical success constituted placement of a guidewire in the true lumen, past the distal CTO cap, with the initial crossing strategy.

Results: A wire-catheter strategy was used in 295 (67.4%) and a specialized CTO crossing device in 143 (32.6%) patients (p<0.001). Primary crossing technical success was higher with CTO devices (72.1% vs 51.9%, p<0.001). The primary wire-catheter arm used significantly more secondary CTO devices (28.1% vs 17.5%) and/or provisional re-entry devices (26.7% vs 4.9%) compared with the primary CTO device arm (both p<0.001). Secondary crossing technical success (defined as crossing with an alternate strategy: 67.5% vs 71.4%, p=1.000), provisional crossing technical success (defined as use of a re-entry device: 84.2% vs 87.5%, p=0.768), and procedure success (93.6% vs 90.9%, p=0.332) were similar between the wire-catheter and CTO device strategies, respectively. No differences were observed in periprocedural complications or 30-day adverse events; however, at 12 months, there was a significantly higher surgical revascularization rate in the primary wire-catheter arm (8.8% vs 2.8%, p=0.025).

Conclusion: Infrainguinal peripheral artery CTO crossing is frequently attempted with a wire-catheter technique; however, an initial CTO crossing device approach is associated with higher primary technical success. Overall procedure success is similar with both strategies.

Keywords: anterior tibial artery; chronic total occlusion; crossing device; endovascular procedures; guidewire; microcatheter; occlusion; peripheral artery disease; peroneal artery; popliteal artery; posterior tibial artery; stenosis; superficial femoral artery.

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