ABSTRACT
Crossing total occlusions Femoropopliteal CTOs are effectively treated with up-andover techniques, whereas iliac lesions are often best approached via ipsilateral retrograde femoral access. In order to provide the support needed to cross long infrainguinal lesions, a long 6-or 7-French sheath like Ansel or Raabe (Cook Inc., Bloomington, IN) is placed over the iliac bifurcation with the tip into the superficial femoral artery. Once the access is obtained, the patient is anticoagulated with either heparin or bivalirudin. We often use a combination of a hydrophilic guidewire such as a 0.035-inch Glidewire (Terumo, Somerset, NJ), and a support catheter such as the 4-5-French angled Glidecath as initial approach for crossing a CTO. The procedure from this point on requires road-map imaging to visualize the distal vessel as angiographic imaging through the support catheter is largely unhelpful. It is important that the hydrophilic guidewire enters the occlusion with the tip straight without any spiraling as this allows for the proper tip engagement into the lesion. At this point one can either attempt crossing intraluminally or looping the wire purposely to enter subintimal space. Despite the counterintuitive nature of starting a subintimal plane intentionally, the technique is relatively simple and usually more successful (70-90% of cases) than intentional true lumen passage for long-segment CTOs.9
