Given the breadth of procedures, complexity, variability in anatomy, and vascular approach in the periphery, there are a plethora of available wires, introducer sheaths, and delivery, diagnostic, and interventional guiding catheters. Many of the available devices are shown in Tables 6 and 7 (see p. 48 and 49).

Table 6

Peripheral wires.

Table 7

Guiding catheters/sheaths.

Two unique devices are available for crossing total occlusions in lower extremity arteries. The CrossPoint TransAccess catheter (Medtronic) allows for controlled re-entry into the distal vessel following purposeful subintimal entry of the proximal occlusion using intravascular ultrasound (IVUS) guidance (see Figure 3). The device is placed proximal to the occlusion using a contralateral approach. It is compatible with a 7-Fr sheath, and has an internal diameter of 0.087 inches and a shaft length of 120 cm. The 6.2-Fr catheter tracks over a 0.014-inch guidewire, and a 24-G needle at the near tip of the catheter allows the delivery of a 0.014-inch wire into the distal artery. Ultrasound facilitates the entry of the needle into the true arterial lumen. An integrated 64-element phased-array 20-MHz IVUS transducer at the tip of the catheter enables use with the Jomed/Endosonics IVUS console. IVUS imaging is used to direct the needle towards the true lumen. A 0.014-inch needle is advanced through the CrossPoint needle in order to gain access to the true distal lumen.

Figure 3

The CrossPoint TransAccess Catheter (Medtronic Vascular, Minneapolis, MN, USA).

The Safe-Cross Total Occlusion RF Crossing Wire (IntraLuminal Therapeutics, Carlsbad, CA, USA) is a forward-looking guidance device that uses optical coherence reflectometry for guidance and radiofrequency energy for microablation of the lesion (see Figure 4). The guidance works through a fiberoptic strand that is located in the center of the guidewire and looks out the distal tip of the wire. By analyzing the reflection of near infrared light from the tissue adjacent to the guidewire tip, the proximity to the arterial wall can be determined and displayed to the operator. If the guidewire is within the lumen of the artery and not near the artery wall, the radiofrequency energy can be used for microablation at the distal tip of the guidewire, such that the operator can create small voids and fissures in the occlusion to facilitate advancement of the guidewire. This guidewire system recently received market clearance from the Food and Drug Administration for use in coronary, iliac, and superficial femoral arteries.

Figure 4

The Safe-Cross system (IntraLuminal Therapeutics, Carlsbad, CA, USA). (a) The Safe-Cross console and display. (b) The Safe-Cross crossing wire. The crossing wire has multiple tip configurations (straight and angled) and multiple sizes for coronary and (more...)