The IX t h Makassed Medical Congress - American University of Beirut

T h e I X t h M a k a s e d M e d i c a l C o n g r e s s
ADVANCES IN TREATING PERIPHERAL CHRONIC TOTAL OCCLUSIONS
Mohammad Zgheib, M.D
Peripheral Vascular Disease (PVD) is highly prevalent and underdiagnosed. More than 50% of
physicians are unaware of PAD at screening. Thus, patients with PAD have an increased risk of
morbidity and mortality. Risk factors for PAD includes DM, smoking, hyperlipidemia, hypertension
and hyperhomocysteinemia. PAD often occurs with other manifestations of atherosclerosis,
including cerebrovascular and cardiovascular disease.Among men with PAD, 29.4% had
cardiovascular disease. Among women with PAD, 21.2% had CVD. In comparison, 11.5% of men
and 9.3% of women without PAD had a history of CVD. Thus, in this study, other CVD occurred two
to three times more frequently among persons with PAD.
Intermittent claudication is the most common manifestation of PAD. A small percentage of
patients with intermittent claudication (1.5–5%) develop critical leg ischemia, which causes pain
at rest and may result in gangrene and amputation of the affected limb.
Beside physical exam several non-invasive testing play an important position in the testing of
patients for PAD that may include ABI, segmental pressure, PVR, duplex ultrasound CT angiography
and/or MRA.
Managing PAD is essentially by risk factors modification. In patients with PAD, morbidity and
mortality can be significantly decreased by stopping smoking, taking regular exercise (three times
a day), and reducing dietary fat intake. Importantly, pharmacological treatment should include
secondary prevention of ischemic events of atherothrombotic origin by an antiplatelet agent.
Pharmacological treatment to reduce cholesterol, and to control diabetes and hypertension,
where present, is also important. These risk-factor modification strategies also apply to reduction
of ischemic risk in patients with symptomatic atherosclerosis affecting the coronary and cerebral
arterial beds.
Intervention, either by direct reconstruction of diseased leg arteries by angioplasty (with or without
subsequent stent placement), endarterectomy or by replacement by peripheral bypass grafting,
can relieve symptoms caused by inadequate blood flow. The decision to operate should be
based on symptom severity, degree of disability and perceived surgical risk.
The number of percutaneous revascularization procedures performed for symptomatic peripheral
arterial disease (PAD) has significantly increased over the past several years. Traditionally, the
use of percutaneous techniques were limited to certain anatomic subsets, such as stenosis or
focal occlusions, with surgical treatment preferred for more extensive disease. More recently,
endovascular specialists are facing the challenges of treating commonly- encountered peripheral
chronic total occlusions (CTOs). Peripheral CTOs remain one of the most challenging lesions for
the endovascular specialist. Unlike the coronary circulation, these occlusions are often long and
associated with other features of complexity.
There are several techniques for crossing CTOs. The most recent one is the use of the CROSSER
catheter that mechanically vibrates against a CTO. It allows central lumen navigation and avoid
subintimal dissection that may benefit long term outcomes and optimize adjunctive treatments
like atherectomy, PTA and/or stenting. Innovative technology is essential if long, calcified, and
chronic occlusions are to be successfully recanalized without acute complications and with
satisfactory short- and long-term outcomes. Although treatment of CTOs remains challenging
and requires patience and knowledge of many devices, clinical success leads to significant
improvement in the quality of life and, for some, limb salvage, and is therefore rewarding.
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