Tools of the Trade: Adjunctive Tools for Lesion Crossing in Critical Limb Ischemia

Critical limb ischemia (CLI) due to obstructive atherosclerosis causes pain and tissue damage and may result in amputation and death. Revascularization saves the limbs and lives of patients with CLI. This review addresses adjunctive tools for lesion crossing, including mechanical atherectomy, laser atherectomy, crossing devices, and luminal reentry devices. Mechanical atherectomy devices are designed to excise atheroma, often heavily calcified, thereby preparing a channel for further intervention. Mechanisms (and devices) include directional (SilverHawk™, TurboHawk™, RockHawk™), rotational (Jetstream™, Pheonix™), and orbital (Diamondback 360°™, Predator 360°™, Stealth 360°™) atherectomy. A laser atherectomy device (Turbo Elite™) vaporizes atheroma by heating tissues with ultraviolet light. Crossing devices specifically designed for chronic total occlusions either navigate a vessel’s true lumen or guide a controlled subintimal course with reentry into the distal true lumen. Crossing devices include Crosser® Catheter, Wildcat™, Ocelot™, Kittycat™, TruePath™, Viance™, Frontrunner™, TOTAL across™, and PowerWire™. When a guidewire or crossing device traverses a lesion via a subintimal course, a luminal reentry device may facilitate deployment of the guidewire in the distal vessel lumen. Reentry devices include Outback LTD™, Offroad™, Pioneer Plus™, and Enteer™.