Cardiology and Vascular Medicine, GRN Hospital Weinheim, Germany.
Department of Interventional Angiology, University Hospital Leipzig, Germany.
Vasa. 2023 May;52(3):147-159. doi: 10.1024/0301-1526/a001066. Epub 2023 Mar 16.
Together with colleagues from different disciplines, including cardiologists, interventional radiologists and vascular surgeons, committee members of the of the German Society of Angiology ( []), developed a novel algorithm for the endovascular treatment of peripheral chronic total occlusive lesions (CTOs). Our aim is to improve patient and limb related outcomes, by increasing the success rate of endovascular procedures. This can be achieved by adherence to the proposed crossing algorithm, aiding the standardization of endovascular procedures. The following steps are proposed: (i) APPLY Duplex sonography and if required 3D techniques such as computed tomography or magnetic resonance angiography. This will help you to select the optimal access site. (ii) EVALUATE the CTO cap morphology and distal vessel refilling sites during diagnostic angiography, which are potential targets for a retrograde access. (iii) START with antegrade wiring strategies including guidewire (GW) and support catheter technology. Use GW escalation strategies to penetrate the proximal cap of the CTO, which may usually be fibrotic and calcified. (iv) STOP the antegrade attempt depending on patient specific parameters and the presence of retrograde options, as evaluated by pre-procedural imaging and during angiography. (v) In case of FAILURE, consider advanced bidirectional techniques and reentry devices. (vi) In case of SUCCESS, externalize the GW and treat the CTO. Manage the retrograde access at the end of the endovascular procedure. (vii) STOP the procedure if no progress can be obtained within 3 hours, in case of specific complications or when reaching maximum contrast administration based on individual patient's renal function. Consider radiation exposure both for patients and operators. In this manuscript we systematically follow and explain each of the steps (i)-(vi) based on practical examples from our daily routine. We strongly believe that the integration of this algorithm in the daily practice of endovascular specialists, can improve vessel and patient specific outcomes.
德国血管外科学会（[]）的委员会成员与来自不同学科的同事（包括心脏病专家、介入放射学家和血管外科医生）一起，为外周慢性全闭塞病变（CTO）的血管内治疗开发了一种新的算法。我们的目标是通过提高血管内手术的成功率来改善患者和肢体相关的结果。这可以通过遵守提出的交叉算法来实现，辅助血管内手术的标准化。提出了以下步骤：（i）应用双功能超声，如果需要，还可以使用 3D 技术，如计算机断层扫描或磁共振血管造影术。这将有助于选择最佳的入路部位。（ii）在诊断性血管造影期间评估 CTO 帽形态和远端血管再填充部位，这些部位可能是逆行入路的潜在靶点。（iii）从顺行布线策略开始，包括导丝（GW）和支持导管技术。使用 GW 升级策略穿透 CTO 的近端帽，近端帽通常是纤维化和钙化的。（iv）根据患者特定参数和术前成像及血管造影期间评估的逆行选择，停止顺行尝试。（v）如果失败，考虑使用先进的双向技术和再入装置。（vi）如果成功，将 GW 引出并治疗 CTO。在血管内手术结束时处理逆行入路。（vii）如果在 3 小时内无法获得进展，或出现特定并发症，或根据个体患者的肾功能达到最大造影剂用量，则停止手术。考虑患者和操作人员的辐射暴露。在本文中，我们根据日常实践中的实际例子，系统地解释了步骤（i）-（vi）中的每一步。我们坚信，将该算法纳入血管内专家的日常实践中，可以改善血管和患者的具体结果。
