Antegrade Crossing Techniques for Hard Proximal Occlusion Caps Without the Use of Dedicated Chronic Total Occlusion Devices: A Pictorial Review

One of the main skillsets required to tackle endovascular revascularization of complex peripheral chronic total occlusions (CTOs) is wire crossing into the distal true lumen. There are a lot of factors that influence the use of specific catheter and wire strategies, and these include vessel calcification, occlusion length, previous stents, vessel reconstitution zone, availability of retrograde access, operator experience, and available equipment of the shelf. More than the last 2 decades, various dedicated CTO devices have been developed to meet these specific clinical needs; however, their widespread use has been limited by the lack of availability around the world and considerable cost. Hence, the ability to cross complex lesions with the use of widely available simple catheters and wires is crucial for effective limb salvage in this significantly undertreated patient population. The customization of specific techniques to treat individual patients and anatomical subsets is one of the most creative and innovative aspects of the endovascular revascularization field.Clinical ImpactInfra-inguinal Chronic Total Occlusions recanalisation is considered technically challenging. The conventional manipulation of standard guidewires and catheters has proven to be successful in a considerable percentage of cases but success rate could dramatically drop in presence of challenging lesions. The additional use of retrograde access and re-entry devices could increase technical success but could negatively affect procedural time and overall costs. Twenty different techniques of Chronic Total Occlusions antegrade crossing are hereby described with appropriate schematic representations. The aim is to help operators to apply them in specific anatomy subsets and clinical presentations and ultimately to increase procedural success rate.