GRN Hospital Weinheim, Cardiology and Vascular Medicine, Weinheim, Germany.
Division of Angiology, Department of Internal Medicine, Neurology and Dermatology, University Hospital Leipzig, Leipzig, Germany.
JACC Cardiovasc Interv. 2023 Feb 13;16(3):317-331. doi: 10.1016/j.jcin.2022.11.036.
A crossing algorithm was developed for the endovascular treatment of peripheral chronic total occlusive lesions (CTOs) to educate, guide, and appropriately influence clinical practice aiming at harmonization and standardization of endovascular procedures. The following steps are proposed: One, duplex sonography and if required computed tomography or magnetic resonance angiography for the selection of the optimal access site. Two, angiographic evaluation of the proximal/distal cap morphology, presence of collaterals at the origin of the proximal cap and at the distal vessel refilling site. In addition, evaluation of distal vessels, including their diameters and quality, and the presence of calcification or stents within the occlusion zone. Three, antegrade wiring strategies, guidewire (GW) and support catheter technology, as well as GW escalation strategies. Stop the antegrade attempt depending on clinical indication for peripheral artery disease treatment and the presence of retrograde options. Four, retrograde access site, support catheter, or sheath insertion and wiring technology from distally. Five, considering strategy change when progress cannot by achieved, using advanced bidirectional techniques and re-entry devices. Six, in case of successful GW passage from retrograde, GW externalization and treatment from antegrade. Management of the retrograde access by internal or external hemostasis at the end of the procedure. Alternatively, stop the procedure if no progress can be obtained within 3 hours or in case of specific complications. By establishing the algorithm in the daily routine of endovascular specialists, improvements in vessel- and patient-specific outcomes are anticipated. In addition, future research, and continuous collaboration between experts is warranted.
开发了一种用于外周慢性完全闭塞病变（CTO）血管内治疗的交叉算法，旨在教育、指导和适当影响临床实践，以实现血管内程序的协调和标准化。提出了以下步骤：一是采用双功能超声，如果需要还可采用计算机断层扫描或磁共振血管造影，选择最佳入路。二是对近端/远端闭塞帽形态、近端闭塞帽起源处和远端血管再充盈部位侧支循环的存在进行血管造影评估。此外，评估远端血管，包括其直径和质量，以及闭塞区域内是否存在钙化或支架。三是顺行布线策略、导丝（GW）和支持导管技术，以及 GW 升级策略。根据外周动脉疾病治疗的临床指征和逆行选择的存在，停止顺行尝试。四是逆行入路、支持导管或护套的插入和从远端进行布线技术。五是在无法取得进展时考虑改变策略，使用先进的双向技术和再进入装置。六是如果能够从逆行成功通过 GW，则从顺行进行 GW 引出和治疗。在手术结束时通过内部或外部止血来管理逆行入路。或者，如果在 3 小时内无法取得进展或出现特定并发症，则停止手术。通过在血管内专家的日常工作中建立该算法，预计会改善血管和患者特异性的结果。此外，还需要进行未来的研究和专家之间的持续合作。
