Chronic total occlusions (CTOs) comprise a large percentage of lower extremity arterial interventions. Numerous methods are available for crossing where the expertise of the operator typically guides the approach. In my opinion, true lumen antegrade CTO crossing would be the preferred approach if achievable. Yet in long CTOs with complex plaque morphologies, the mantra of “keep it simple, stupid” is not always possible. Thus, we typically have to acquire expertise in alternate means of re-entry such as controlled antegrade-retrograde subintimal tracking (CART), reverse CART, trans-collateral crossing, or utilizing re-entry tools, to name a few methods. All of these methods require specialized skills to avoid complications, can add to procedural cost, and can increase radiation exposure. These crossing techniques often yield high grade dissections requiring the need for a bail-out stent strategy.
While stent patency is improving, I personally would favor a stent-free approach, if at all possible, given the efficacy of drug-coated balloons. Thus, the discovery of new technologies intended to assist and streamline antegrade, true lumen CTO crossing are a welcomed addition to the interventionists toolbox.
In this New Technologies in Vascular Disease Management, we are privileged to have Drs Frank Pomposelli, Jr, MD, and Albert K. Chin, MD, introduce our readers to an innovative device, the Houdini Catheter (Cruzar Medsystems, Braintree, Massachusetts) for crossing peripheral CTOs. This catheter contains an everting inner lumen and a distal centering balloon that imparts hydraulic pressure and optimizes vector force to drive a central guidewire through the CTO under mechanical control of the operator. Ultimately, it may help achieve the goal of true lumen CTO crossing. As clinical experience with this device grows, it will be of value to demonstrate whether use of this device and the intended goal of successful true lumen crossing could potentially yield improved patient outcomes. We congratulate the entire team involved with the development of this innovative technology.