Chronic Total Occlusion Crossing Approach Based on Plaque Cap Morphology: The CTOP Classification

Saab, Fadi; Jaff, Michael R.; Díaz‐Sandoval, Larry J.; Engen, Gwennan D; McGoff, Theresa; Adams, George L.; Al-Dadah, Ashraf; Goodney, Philip P.; Khawaja, Farhan J.; Mustapha, Jihad

doi:10.1177/1526602818759333

Cited by 67 publications

(60 citation statements)

References 17 publications

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“…Even if their combination and the creation of a scoring system is novel, the variables themselves have also been shown in the past to have a significant association with successful crossing. Recently the chronic total occlusion crossing approach based on plaque cap morphology (CTOP) classification was published by Saab et al They studied peripheral artery CTOs (not limited to IP) and they tried to classify these lesions based on the CTO cap morphology with the help of angiography and duplex ultrasonography. They classified the lesions to four different types based on the proximal and distal CTO cap (as encountered from an anterograde approach).…”

Section: Discussionmentioning

confidence: 99%

“…The angiographic analysis did not take into account the distal cap and the possible presence of additional CTO caps after the proximal cap which could have further increased the crossing difficulty. Moreover, an ultrasound was not used to better assess the morphology and other characteristics of the lesions in contrast to other recent studies evaluation cap morphology . Restenosis cases were included in this study even if this could have led to risk for biased results.…”

Section: Discussionmentioning

confidence: 99%

“…The proximal CTO stump was initially classified as blunt or central. Central stumps were further categorized as string, eccentric, beaded, triangle, or convex according to the angiographic morphology . Other angiographic characteristics assessed were the existence of bridging collaterals, side braches, side branches <1.5 or ≥ 1.5 mm and the presence of multiple side branches.…”

Section: Methodsmentioning

confidence: 99%

“…Traditionally, CTOs are the most challenging to treat peripheral lesions secondary to an obstructive combination of collagen, atherosclerotic plaque, and calcification. Two different crossing approaches can be used for the endovascular therapy of IP CTO crossing: anterograde and retrograde after tibiopedal access . Most interventionalists prefer to start with the technically easier anterograde approach.…”

Section: Introductionmentioning

confidence: 99%

“…Most interventionalists prefer to start with the technically easier anterograde approach. With failure rates ranging from 20 to 40% across the literature, a switch to tibiopedal access and retrograde crossing is often pursued in the event that anterograde crossing is not successful . However, this leads to increased operative times, radiation exposure and contrast use, and to a higher risk for complications.…”

Section: Introductionmentioning

confidence: 99%

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Development and validation of a predictive score for anterograde crossing of infrapopliteal chronic total occlusions: (The Infrapop‐CTO Score)

Kokkinidis

Strobel

Jawaid

et al. 2020

Cathet Cardio Intervent

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Background Patients with critical limb ischemia often have infrapopliteal (IP) chronic total occlusions (CTOs). While revascularization is indicated to prevent major amputation, anterograde crossing of these lesions can be challenging, with high failure rates. Objective To develop and validate a scoring system that can adequately predict successful anterograde crossing of infrapopliteal CTOs. Methods and Results A total of 213 IP CTOs (147 successfully crossed with the anterograde approach vs. 66 where anterograde crossing failed) were included in the analysis. Backwards stepwise selection (p for retention <.05) was used to create a multivariable logistic regression model for the prediction of successful anterograde crossing using variables that were found to have a p < .1 in univariate analysis. The model was internally validated with bootstrapping and demonstrated excellent discriminatory ability (C‐statistic 0.78 and Hosmer‐Lemeshow p value = .61). A point score based on the beta‐coefficient of the model variables was created, with one point assigned for presence of a noncentral (blunt) stump, one point for severe calcification at the entry site, and two points each for non‐restenotic lesions or lesion length > 200 mm. The score was shown to have an excellent discriminatory ability for successful crossing, with low scores (0–2) associated with low failure rates (10%) and high scores associated with high failure rates (79%). Conclusions The Infrapop‐CTO score can stratify the procedural complexity of IP CTOs based on the likelihood of successful anterograde crossing. This score may help to direct optimal approaches toward infrapopliteal revascularization of patients with critical limb ischemia.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Methodsmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Development and validation of a predictive score for anterograde crossing of infrapopliteal chronic total occlusions: (The Infrapop‐CTO Score)

Kokkinidis

Strobel

Jawaid

et al. 2020

Cathet Cardio Intervent

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Retrograde distal access versus femoral access for below the knee angioplasty

Toledo Barros,

Fonseca,

Amorim

et al. 2024

Cochrane Database of Systematic Reviews

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Tibiopedal arterial minimally invasive retrograde revascularization (TAMI) in patients with peripheral arterial disease and critical limb ischemia. On behalf of the Peripheral Registry of Endovascular Clinical Outcomes (PRIME)

Mustapha¹,

Saab²,

McGoff

et al. 2019

Cathet Cardio Intervent

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Objectives and background Complex peripheral arterial disease (PAD) and critical limb ischemia (CLI) are associated with high morbidity and mortality. Endovascular techniques have become prevalent in treatment of advanced PAD and CLI, and use of techniques such as tibiopedal minimally invasive revascularization (TAMI), have been proven safe in small, single‐center series. However, its use has not been systematically compared to traditional approaches. Methods and results This is a retrospective, multicenter analysis which enrolled 744 patients with advanced PAD and CLI who underwent 1,195 endovascular interventions between January 2013 and April 2018. Data was analyzed based on access used for revascularization: 840 performed via femoral access, 254 via dual access, and 101 via TAMI. The dual access group had the highest median Rutherford Class and lowest number of patent tibial vessels. Median fluoroscopy time, procedure time, hospital stay, and contrast volume were significantly lower in the TAMI access group when compared to both femoral/dual access groups. There was also a significant difference between all groups regarding location of target lesions: Femoropopliteal lesions were most commonly treated via femoral access; infrapopliteal lesions, via TAMI, and multilevel lesions via dual access. Conclusions Stand‐alone TAMI or tibial access as an integral part of a dual access treatment strategy, is safe and efficacious in the treatment of patients with advanced PAD and CLI who have infrapopliteal lesions. Larger prospective and randomized studies may be useful to further validate this approach.

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Chronic Total Occlusion Crossing Approach Based on Plaque Cap Morphology: The CTOP Classification

Abstract: CTOP type I lesions were easiest to cross in antegrade fashion and type IV the most difficult. Lesion length >10 cm, severe calcification, and CTO types II, III, and IV benefited from the addition of retrograde tibiopedal access.

Cited by 67 publications

References 17 publications

Development and validation of a predictive score for anterograde crossing of infrapopliteal chronic total occlusions: (The Infrapop‐CTO Score)

Development and validation of a predictive score for anterograde crossing of infrapopliteal chronic total occlusions: (The Infrapop‐CTO Score)

Retrograde distal access versus femoral access for below the knee angioplasty

Tibiopedal arterial minimally invasive retrograde revascularization (TAMI) in patients with peripheral arterial disease and critical limb ischemia. On behalf of the Peripheral Registry of Endovascular Clinical Outcomes (PRIME)

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