A percutaneous crossing algorithm for femoropopliteal and tibial artery chronic total occlusions (PCTO Algorithm)

Subhash Banerjee, Mehdi H. Shishehbor, Jihad A. Mustapha, Ehrin J. Armstrong, Mohammad Ansari, John H. Rundback, Bryan Fisher, Constantino S. Pena, Emmanouil S. Brilakis, Arthur C. Lee, Sahil Parikh

Research output: Contribution to journalArticlepeer-review

11 Scopus citations


Peripheral artery chronic total occlusions (PCTOs) are frequently encountered during endovascular treatment of peripheral artery disease. Failure to successfully cross PCTOs accounts for the majority of unsuccessful endovascular procedures and associated complications. This review outlines a contemporary ultrasound-based approach to crossing femoropopliteal (FP) PCTOs based on a review of prospectively collected case report surveys, published evidence, and expert opinion compiled by the writing group members. The authors describe optimal imaging of PCTO lesions as well as key angiographic and ultrasound imaging features for determining the choice of antegrade, retrograde, or hybrid techniques, initial guidewire selection, guidewire escalation, and dissection re-entry approaches. These concepts are illustrated using clearly defined hierarchical steps and case examples. The writing group members recognize that while the algorithm provided may not encompass all clinical situations, it will serve as a foundation for establishing a systematic procedural strategy for crossing PCTOs to maximize crossing efficiency, treatment success, and patient safety.

Original languageEnglish (US)
Pages (from-to)111-119
Number of pages9
JournalJournal of Invasive Cardiology
Issue number4
StatePublished - 2019


  • Chronic total occlusion
  • Peripheral artery disease

ASJC Scopus subject areas

  • Radiology Nuclear Medicine and imaging
  • Cardiology and Cardiovascular Medicine


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