Technical Success Rates of Endovascular Treatment of Femoropopliteal Chronic Total Occlusions

BACKGROUND: There is limited data on immediate and longerterm outcomes of crossing femoropopliteal (FP) chronic total occlusions (CTO). METHODS: Consecutive patients between January 2006 and March 2015 undergoing endovascular revascularization for symptomatic peripheral artery disease with FP CTO were analyzed as part of the Excellence in Peripheral Artery Disease (XLPAD) registry. Procedural success was defined as restoration of flow through the lesion with ≤30% residual stenosis. Procedural failures included technical failures (defined as failure to cross the CTO or failure to renter the true lumen from the subintimal space) and treatment failures (defined as >30% residual stenosis after successful crossing). One year outcomes were analyzed. RESULTS: A total of 1100 CTO lesions from 948 patients were included in the analysis. Procedural success was achieved in 989 (89.9%) CTO, while procedural failure occurred in 111 (10.1%). Treatment failures comprised 23 (2.1%) and technical failures 88 (8.0%), with 59 (5.4%) intraluminal failures to cross and 29 (2.6%) failures to re-enter from subintimal space. There were significantly more surgical revascularizations following failed procedures compared to successful (13.5% vs. 3.9%;p<0.01), although with a lower need for repeat revascularization procedures (6.3% vs. 20.5%; p<0.01). Need for amputations were similar for patients with failed or successful procedures (5.4% vs. 3.3%; p=.26). Multivariable analysis showed lesion calcification to be an independent predictor of procedural success (p=.03) and multilevel FP disease an independent predictor of procedural failure (p=.03). CONCLUSION: Patients experiencing procedural failures undergo significantly higher rates of surgical revascularization, albeit with lower need for repeat revascularization. Multilevel disease and lesion calcification should both be considered when planning procedural strategy in crossing FP CTO. Further analysis will explore a link between procedural success in calcified lesions and the use of dedicated CTO crossing devices.