FrontRunner and CrossLock: A New Treatment Regimen in Complex Peripheral CTOs
By Richard R. Heuser, MD, FACC, FACP, FESC, FSCAI
In one day this past week, we treated 3 patients with severe ostial superficial femoral artery (SFA) occlusion and critical limb ischemia. All 3 of these cases have one thing in common. We utilized the FrontRunner (Cordis) aided by the CrossLock, a super supportive catheter that is uniquely suited for treating coronary and peripheral chronic total occlusion (CTO). We have had extensive experience and success with the FrontRunner in coronary applications, but these 3 cases delineate how well it works with the CrossLock anchoring device in peripheral applications.
Case 1 History and Methods
A 70-year-old male with an extensive history of tobacco abuse and a non-ischemic cardiomyopathy presented with left-leg claudication for the last 8 years. His claudication is now occurring at rest and affects his left calf. His resting ankle brachial index (ABI) scores were right 1.00, left .80. He underwent angiography via the right femoral artery. A 6 Fr Ansel (Cook Medical) was selectively engaged into the common femoral artery and in spite of the fact that it was difficult to delineate the origin of the SFA, we passed the .014" Command wire (Abbott Vascular) with the CrossLock balloon catheter. The FrontRunner was passed through the Rx port of the CrossLock and with the wire pulled back and the CrossLock balloon inflated, we were able to pass the FrontRunner across the total occlusion. Keeping the .014" wire in place, we removed the FrontRunner and CrossLock and exchanged for a .035" 4 Fr Glide catheter, and it was easy to pass the .035 Glidewire (Terumo Interventional) because we were already intraluminal in the SFA. This was followed by balloon angioplasty and then multiple drug-eluting balloons (Lutonix, Bard Peripheral Vascular). Following this, there was excellent patency and run-off.
Case 2 History and Methods
A 73-year-old female former smoker presented with severe and progressive claudication of her left leg with resting foot pain. Her symptoms began 35 years ago and approximately 10 years ago she had a left iliac artery occlusion that was treated with recanalization and stenting. At the same time her SFA was treated, but after multiple interventions had failed, she underwent femoropopliteal bypass grafting. Unfortunately, she suffered a graft infection and had to have the graft removed. Now she presents with calf claudication and resting pain. A 6 Fr Ansel also confirmed the left SFA was occluded at the origin with an extensive network of collaterals from the deep femoral artery. Using the same technique described in the first case, we passed the FrontRunner through the CrossLock with the CrossLock inflated for super support. We also were able to pass the CrossLock over the FrontRunner with the CrossLock balloon deflated. Following this, as above, we removed the balloon support catheter and FrontRunner and performed focused balloon dilation and multiple drug eluting balloon dilation (Lutonix). Following this, there was excellent 3-vessel run-off.
Case 3 History and Methods
A 55-year-old female former smoker presented with resting pain and a very superficial heel ulcer of her right foot. Five years prior to this admission, she had extensive ulcers and was near amputation of this leg, and we were able to salvage the leg with SFA and infrapopliteal intervention and stenting. Her ABIs were right .66, left 1.05. Going through her left groin, the Ansel showed a 100% occlusion of the proximal SFA vessel. Similar to the previous cases, we used the same technique with the CrossLock and FrontRunner. The CrossLock and FrontRunner were able to be subtended across the previously long occlusion of the SFA. Using the same technique as described above, the patient was left with a widely patent SFA and the distal vessels filled by collaterals. This young lady has done a masterful job of stopping smoking and controlling her diabetes, and she exercises as much as she can with her severe COPD. In the past, with resolving her femoral disease, she had become asymptomatic after treating her femoropopliteal disease. If in the future, she does not improve, we will perform pedal intervention to treat her infrapopliteal vessels.
It is clear that we are treating more and more difficult critical ischemic patients. Blunt access is necessary in calcific, hard, 100% occlusions, but this can result in arterial trauma. The CrossLock catheter with balloon inflation can center the lumen, which can aid in crossing a CTO. The blunt FrontRunner has the ability to cross a difficult CTO either with just the blunt tip or the jaws to ablate and disrupt the plaque. In all 3 of these cases, we quickly passed the proximal cap of the CTO and maintained an intraluminal position. This very successful and rapid technique may be useful for other operators performing these complex CTO interventions. The CrossLock is an Rx catheter and the FrontRunner is an over-the-wire catheter, but using the Rx port of the CrossLock, the FrontRunner works very well. We have also performed laser, balloon angioplasty, and stenting with the CrossLock successfully.
We describe a new approach for treating peripheral and potentially coronary CTOs. Unlike any other catheter, we were able to use the centering aspect of the CrossLock to maintain and intraluminal position and use the aggressive crossing strength of the FrontRunner to perform recanalization. We feel from our experience we may be able to make the procedures go more quickly with utilization of less contrast and fluoroscopy with a high degree of success and safety.
Images and Videos (click images to enlarge)
Figure 1, Video 1. Total occlusion of the SFA.
Figure 2, Video 2. Note the absence of a true origin treatment zone.
Figure 3, Video 3. The CrossLock has been passed over a .014" wire and the FrontRunner is also in place. Note the balloon on the CrossLock is inflated centering the lumen for passage of the FrontRunner. It subtends the CTO in real time.
Figure 4, Video 4. The CrossLock has been deflated, and it is advanced over the FrontRunner.
Figure 5, Video 5. The CrossLock and FrontRunner were removed and a Glide catheter was passed over the .014 wire and an .035 wire is now passed in an intraluminal position.
Figure 6. Video 6. Final angiogram showing 3 vessel runoff.
Figure 7, Video 7. The initial angiogram reveals the small bud of the SFA CTO. Note the extensive deep femoral artery collaterals.
Figure 8, Video 8. The sheath and the bud of the CTO.
Figure 9, Video 9. The CrossLock™ balloon inflated centering the lumen.
Figure 10, Video 10. With the CrossLock™ inflated, the FrontRunner stays intraluminal during this real time video.
Figure 11, Video 11. The Glide catheter is clearly in the intraluminal position, and we have recanalized the CTO.
Figure 12, Video 12. Final result.
Figure 13, Video 13. Initial angiogram shows the SFA CTO after a short segment of a patent vessel.
Figure 14, Video 14. DSA view.
Figure 15, Video 15. Selective view delineates the target.
Figure 16, Video 16. The CrossLock has centered the lumen and the FrontRunner is ready to be passed.
Figure 17, Video 17. The FrontRunner has the jaws open approaching the proximal cap of the CTO.
Figure 18, Video 18. Passage of the FrontRunner™ in real time with the support of the CrossLock.
Figure 19, Video 19. We are now able to pass the CrossLock™ distally (shown in real time).
Figure 20, Video 20. Final angiogram.