Cunier Marc, Najafi Arash, Sheikh Gabriel T, Binkert Christoph A
Department of Radiology and Nuclear medicine, Canton Hospital Winterthur, 8401, Winterthur, Switzerland.
CVIR Endovasc. 2019 Jul 18;2(1):23. doi: 10.1186/s42155-019-0065-1.
The standard approach for crossing peripheral CTOs is to use a combination of hydrophilic guidewires and catheters. The path is either intraluminally or in most cases at least partially subintimal. This standard approach with a guidewire-tip as leading point ("wire first") to cross CTOs has a success rate of about 80%. We hypothesize that a "catheter first" approach, using the catheter alone for the entire recanalization till re-entering the vessel is less traumatic and might lead to a longer intraluminal recanalization due to a softer leading point. Based on this assumption we analyzed the success and duration of this approach with a gradual step-up approach from catheter tip to guidewire front-end to guidewire back-end. To the best of our knowledge, no studies measuring the time of recanalization of lower extremity CTOs using conventional devices were published yet.
Data of 46 consecutive chronic total iliaco-femoro-popliteal occlusions in 43 symptomatic patients treated by percutaneous transluminal angioplasty were collected prospectively between May 1st 2014 and June 30th 2016 and evaluated retrospectively. Chronic occlusion was defined as clinical symptoms or imaging features lasting more than 1 month. Patient age and gender, diabetes status, localization of occlusion, occlusion length, duration of symptoms, severity of vessel calcification, and recanalization time were assessed. Technical success was defined as placement of a catheter beyond the distal end of the lesion into the true lumen, confirmed by contrast injection. All 46 CTOs were successfully recanalized. In 22 cases (47.8%) recanalization was successful with the catheter tip only without the use of a guide wire. In 17 cases (36.9%) the guide wire was used in addition to the catheter. Localization of occlusion did not have an effect on the recanalization technique (p = 0.915). The mean rank for length of occlusion was not significant for different recanalization techniques (p = 0.095). The success rate for the catheter only approach was lower for higher grades of calcification (p = 0.008). There was no correlation between time of recanalization and length of occlusion (Pearson's r = 0.004; adjusted R square = - 0.024; p = 0.980), diabetes (p = 1.000), sex (p = 0.244), or grade of calcification (p = 0.621). Recanalization time is significantly right-skewed with most recanalizations being successful under 30 min.
This "catheter first" approach is somewhat contradictory to the prevailing dogma of "wire first". The concept to use the catheter to start a recanalization is well known, but to perform the entire recanalization including the re-entry seems possible and potentially less traumatic, likely leading to a longer intraluminal course. Our data shows that recanalization of occluded lower extremity arteries between the aortic bifurcation and the popliteal artery can be achieved in the majority of cases (84.7%) solely by using an angled angiographic catheter +/- glide wire. We suggest a "5 min - 15 min - 30 min" rule on how long to attempt each recanalization technique. More precisely, we suggest trying 5 min with the catheter alone, then 10 min with the soft end of the guidewire and then switching to the stiffer back-end of the guidewire for another 15 min.
外周慢性完全闭塞病变（CTO）的标准开通方法是联合使用亲水导丝和导管。路径可以是管腔内的，或者在大多数情况下至少部分是内膜下的。这种以导丝尖端为引导点（“导丝优先”）来开通CTO的标准方法成功率约为80%。我们推测，“导管优先”方法，即在整个再通直至重新进入血管的过程中仅使用导管，创伤较小，并且由于引导点更柔软，可能会实现更长的管腔内再通。基于这一假设，我们采用从导管尖端到导丝前端再到导丝后端的逐步递进方法，分析了该方法的成功率和持续时间。据我们所知，尚未有使用传统器械测量下肢CTO再通时间的研究发表。
前瞻性收集了2014年5月1日至2016年6月30日期间43例有症状患者中46例连续性慢性髂股腘动脉完全闭塞病变的数据，并进行回顾性评估。慢性闭塞定义为临床症状或影像学特征持续超过1个月。评估了患者年龄和性别、糖尿病状态、闭塞部位、闭塞长度、症状持续时间、血管钙化程度以及再通时间。技术成功定义为通过造影剂注射确认导管置于病变远端以外的真腔内。所有46例CTO均成功再通。22例（47.8%）仅使用导管尖端即成功再通，未使用导丝。17例（36.9%）除导管外还使用了导丝。闭塞部位对再通技术没有影响（p = 0.915）。不同再通技术的闭塞长度平均秩次无显著差异（p = 0.095）。钙化程度较高时，仅使用导管方法的成功率较低（p = 0.008）。再通时间与闭塞长度（Pearson相关系数r = 0.004；调整后的决定系数R² = -0.024；p = 0.980）、糖尿病（p = 1.000）、性别（p = 0.244）或钙化程度（p = 0.621）均无相关性。再通时间明显呈右偏态分布，大多数再通在30分钟内成功。
这种“导管优先”方法与普遍的“导丝优先”教条有些矛盾。使用导管开始再通的概念是众所周知的，但进行包括重新进入在内的整个再通似乎是可行的，并且潜在创伤较小，可能会导致更长的管腔内进程。我们的数据表明，在大多数情况下（84.7%），仅使用成角血管造影导管±滑导丝即可实现主动脉分叉与腘动脉之间闭塞的下肢动脉再通。我们针对每种再通技术的尝试时间提出了一个“5分钟 - 15分钟 - 30分钟”规则。更确切地说，我们建议先单独使用导管尝试5分钟，然后使用导丝的软端尝试10分钟，然后切换到导丝较硬的后端再尝试15分钟。
