Primary Orbital Atherectomy for Difficult Chronic Total Occlusion Crossing

Educational Poster Background: With an increasing volume of lower extremity critical limb ischemia (CLI) revascularizations performed, new techniques are required for heavily calcified chronic total occlusions (CTO). We intend to investigate the feasibility of initial orbital atherectomy over low-profile guidewires, despite intraluminal or subintimal tracts, during CTO revascularizations that are resistant to support catheters/balloon advancement in CLI patients. This has been experienced even with retrograde flossing wire access. With the Institutional Review Board approval, angiograms from 2013 to 2018 were reviewed. Patients with CLI (n = 16, mean age = 69.2, standard deviation age = 12.7, 75.0% male [12/16], 25.0% female [4/16]) were identified. Rutherford classification of the patients included 1 Category 4 (6.3%), 8 Category 5 (50.0%), and 7 Category 6 (37.5%). 17 occlusions were identified in the following arteries (2 in one patient) including eight anterior tibial (50.0%), four posterior tibial (25.0%), two popliteal (12.5%), two peroneal (12.5%), and one tibioperoneal trunk (6.7%). Subintimal course was noted in six cases (37.5%). Following low-profile guidewire crossing, failure of support or balloon catheter advancement was experienced, including coronary balloon catheters. Orbital atherectomy was then performed with a 1.25 or 1.50 mm Diamondback orbital atherectomy device (Cardiovascular Systems Inc., St. Paul, MN, USA), or with the addition of TruePath (Boston Scientific, Boston, MA, USA) in one case, followed by angioplasty and stenting as warranted. Final angiograms demonstrated successful revascularization of the desired vessel in 16 of the 17 procedures (94%). Recanalization was not attained in one anterior tibial artery comprised three distinct occlusions. There were no complications. This retrospective analysis provides preliminary evidence of primary orbital atherectomy feasibility over low-profile guidewire CTO crossing, even if partially subintimal. This technique provides the dual benefit of pretreating the vessel before balloon angioplasty and/or stenting, as well as facilitating device exchange.

Publication History

Article published online:
26 April 2021