Controlled Blunt Microdissection for Percutaneous Recanalization of Lower Limb Arterial Chronic Total Occlusions: A Single Center Experience

Peter J. Mossop, MBBS, Shalini A. Amukotuwa, MBBS, and Robert J. Whitbourn, MBBS

Background: Percutaneous techniques for the revascularization of symptomatic lower limb arterial chronic total occlusions (CTOs) remain suboptimal due to difficulty in safely and reliably crossing these heavily calcified lesions using standard guidewire and balloon technology.

Objectives: The objective of this prospective study was to evaluate the technical success and safety of controlled blunt microdissection (CMD) for the treatment of resistant peripheral CTOs.

Methods: This series enrolled 36 patients (26 men; mean age 67 +/- 12 years), with 44 symptomatic CTOs (2 terminal aortic, 24 iliac, 16 femoral, and 2 popliteal), which had previously failed conventional percutaneous revascularization. CMD was carried out using a specialized prototype catheter. Actuation of the hinged jaws of this CMD catheter created a channel within the occluded arterial segment for guidewire passage, and subsequent angioplasty and stenting using standard procedures. The problem of subintimal CMD catheter passage, creating an eccentric channel, was addressed using a second novel device, the true-lumen reentry (LRE) catheter, which allowed reentry into the downstream lumen.

Results: Procedural success, evaluated angiographically, was achieved in 40 (91%) of the 44 CTOs. Fourteen (35%) of these 40 successful recanalizations required guidewire redirection, using the LRE catheter for lesion traversal. There were no complications related to CMD per se; although one patient experienced acute in-stent thrombosis, managed successfully with intra-arterial thrombolysis.

Conclusions: We therefore conclude that CMD can be used safely and successfully to facilitate recanalization of resistant CTOs in the pelvic and lower limb arteries.

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