Ask The Clinician

Clinical Approach

I have a 74-year-old patient who had an MRA in 2009 showing heavily calcified flush superficial femoral artery occlusion with preserved anterior tibial and posterior tibial arteries. At that time he had claudication but has now progressed to a nonhealing first-toe ulcer. Repeat imaging shows stable above-knee disease with new advanced below-knee tibial disease. Is there a role for popliteal puncture with treatment of his tibial disease to bring him to his prior baseline and leaving the superficial femoral artery, which has been chronically occluded?

The primary goal is to have a direct line of flow to the ischemic tissue. This is best done by opening the angiosome-directed artery. If that is not possible, then we open the second best option. We measure our end points by looking at the following:
1. Angiographic direct flow into the target ischemic tissue
2. Hyperperfusion post revascularization
3. Indirect angiography flow to the ischemic tissue. This is usually done by opening a nondirect artery that ends up feeding the target vessel via collateral or transtibial/transpedal indirect flow.
4. Retrograde flow to the anterior and posterior communicating artery. This is a strong indicator of well-perfused distal pedal bed.
5. Tissue oxygenation at baseline and at 24 hours post revascularization. Repeat it in 7 days. We use SensiLase (Vasamed) and transcutaneous oximetry.
6. The staging procedure, which has become an essential practice in our critical limb ischemia revascularization.
7. If possible, open two tibial vessels for patients with claudication of Rutherford class V or more. This is mostly done during staged revascularization.


I have a 74-year-old patient who had a magnetic resonance angiogram in 2009 that showed heavily calcified flush superficial femoral artery occlusion with preserved anterior tibial and posterior tibial arteries. At that time he had claudication but his disease has now progressed to a nonhealing first-toe ulcer. Repeat imaging shows stable above-knee disease with new advanced below-knee tibial disease. Is there a role for popliteal puncture with treatment of his tibial disease to bring him to his prior baseline and leaving the superficial femoral artery, which has been chronically occluded?

Because the patient has two-vessel run-off, it would be very beneficial to open the chronic superficial femoral artery chronic total occlusion. Although antegrade popliteal access and intervention is a great idea, it still leaves you with uncertainty regarding wether the toe ulcer would heal. Personally, I recommend revascularization of the superficial femoral artery into the tibial arteries.


I have a patient with right toe ischemic necrosis. The superficial femoral angiogram shows a heavily calcified, occluded distal popliteal artery extending to the three vessels as well as extensive collaterals, but there is no good visualization of the distal arteries to the ankle level. CTA was not helpful. What should be done in this case?

The toe involvement indicates disease involving the anterior tibial distribution most of the time. When the whole toe (dorsal and plantar) is involved, this indicates that both anterior tibial and posterior tibial arteries are involved. The next step is to do a retrograde angiogram by accessing the dorsalis pedis or distal anterior tibial artery just above the ankle. The next best option is to access the posterior tibial artery above the ankle and perform the angiogram. Once you have access, give 400 mcg intra-arterial nitroglycerin and perform a retrograde selective angiogram; you will find significant patent tibial vessels. From here, you can snare the retrograde wire and finish your case. Let me know what you find and do.

J. A. Mustapha MD, FACC, FSCAI
Metro Heart and Vascular Institute


What is your basic technique to recanalize an occluded SFA step-by-step? What would be your catheter of choice and so on?

SFA CTO crossing has been a challenge for many years:
First you must start with contralateral access and the support sheath of your choice. My basic technique for crossing an SFA CTO depends on the location and the reconstitution, type of lesion and calcification (mild to severe).
The catheter wire technique is still the most commonly used approach. Personally I use an angled glide wire and angled (0.035) NaviCross catheter. I keep the tip of the glide wire inside the NaviCross catheter and rotate the catheter around the proximal CTO cap. Most of the time the catheter will traverse the CTO cap. If I am unsuccessful, I advance the glide wire and create a curve. I then repeat the catheter rotation until I cross. This technique has been very successful with a crossing rate >80%. An angled CXI catheter (0.018) is another option that can be used with this technique.
I stopped using straight catheters during CTO crossing. This is mainly due to the use of the ultrasound-guided approach at my institution. In my experience, using an angled catheter is more successful in keeping the wire in the true lumen compared to the straight catheter. This approach improves the chance of re-entering from the subintimal space simply by rotating the catheter and advancing it.
My preferred CTO crossing devices include:
• Crosser 14S
• Viance
• Frontrunner
• Avinger catheters (Wildcat)
• TruePath
• Laser

J. A. Mustapha, MD, FACC, FSCAI
Metro Heart and Vascular Institute


What is your basic preferred technique for SFA occlusion recanalization on a step-by-step approach? What catheters and guides do you recommend?

Thank you for your question. This is a very complex topic and answering it would go beyond the context of this format. However, allow me to share some of my practice's basic approaches to this clinical situation. The main issue that needs to be addressed is selecting the access site. Depending on the site of the occlusion, the operator may choose antegrade or retrograde femoral access. For example, if the SFA occlusion is within the mid segment, an antegrade approach might be reasonable. If the occlusion were located within the proximal segment, then contralateral retrograde access would be recommended. A third point would be dealing with flush proximal SFA occlusions. We tend to consider tibial access in these patients in addition to traditional contralateral retrograde access to utilize what we commonly refer to as the SAFARI technique.
In terms of CTO crossing techniques, it is my opinion that the use of CTO crossing devices may aid in preserving the true lumen of the SFA. Whenever feasible, we use a CTO crossing device. However, sometimes the CTO cap characteristics may prohibit such an approach. For example, if the CTO cap is severely calcified with a flush occlusion directing your catheter into a large collateral, then a subintimal dissection technique might be warranted.
Catheters used depend upon operator preference. Allow me to list some of the catheters and wires I traditionally use in different combinations. Our catheter use in these cases includes Navicross, Trailblazer and CXI. Wires often used in my practice in these cases are the traditional Glidewires, and also a milieu of 0.014 and 0.018 wires. For example, we use the Regalia wires, Astato wires, Treasure wires, V-18 and SV5, to name a few.

J. A. Mustapha MD, FACC, FSCAI
Metro Heart and Vascular Institute


I have a 62-year-old gentleman with diabetes and hypertension with SVD (RCA) and proximal total occlusion of the left subclavian artery. What is the best approach in a patient with asymptomatic total occlusion of proximal left subclavian artery?

This is a great question. Allow me to share my practice's experience. In these patients we prefer to obtain retrograde access. Depending upon operator preference, it can be the left radial approach or left brachial approach. Traditionally, we also obtain groin access. The goal of obtaining groin access would be to allow the operator to visualize what is going on in the aortic root while working through the arm. The groin access can be obtained with a 4 Fr or 5 Fr sheath and a catheter of your choice. For example, a pigtail can be placed within the aortic arch. Also choosing between a radial and brachial approach would depend on the operator’s choice of devices. For example, if the operator would like to use a CTO crossing device such as the Crosser device, a 7 Fr sheath would be recommended. If the operator would like to use a covered stent, such as the Icast, a 7 Fr sheath would also be recommended. At this point you are limited to a brachial access. Otherwise, traditional radial approach would be adequate.

J. A. Mustapha MD, FACC, FSCAI
Metro Heart and Vascular Institute


Devices and Equipment

What catheter did Dr. Ramaiah use to cross the superficial femoral artery total occlusion?

The chronic total occlusion was crossed using the Viance catheter made by Covidien.


How often should I consider using a cutting balloon in preparation for the insertion of a peripheral stent? I read that this improves the outcome by reducing restenosis.

The cutting balloon is very effective at scoring calcific lesions to prevent recoil and dissection. Also, if placing a stent, one may get better apposition and expansion. Additionally, it helps to prevent plaque shift so those lesions at bifurcations may benefit from a cutting balloon.

As such, location and morphology of the lesion help determine when a cutting balloon should be used before stent placement.

George L. Adams MD, MHS, FACC
Rex Healthcare (UNC)


Medical Management

Could you discuss antiplatelet medical management for patients preprocedure and postprocedure, for chronic total occlusion in particular?

Once a patient develops Rutherford V classification peripheral artery disease, dual antiplatelet therapy becomes essential, possibly for the duration of the time needed to heal the ulcer. Although there is no class I evidence to support my clinical practice, I have seen good stability provided by long-term dual antiplatelet therapy for patients with Rutherford classifications IV, V, and VI.