A patient presented with a Rutherford class V, nonhealing wound in the distribution of the posterior tibial (PT) artery. Angiography was performed and showed severe tibial disease (Figure 1). Multivessel tibial CTOs over 300 mm in length were also noted. The procedure was initiated with an antegrade selective angiogram showing severe proximal CTOs of the anterior tibial (AT) artery and the PT.

Poor distal tibial runoff and nearly absent flow in the pedal circulation are common in patients with critical limb ischemia. Note the absence of reconstitution of the PT and the faint reconstitution of the AT, making a decision to treat this type of anatomy very challenging, especially with the absence of target reconstitution of the distal CTO. The only artery with some intact flow was the peroneal artery, with intact anterior and posterior communicating arteries but no retrograde or antegrade flow into the PT artery. We chose to use the Crosser® Catheter due to our success rate and level of comfort with this device. In particular, this is the type of CTO where an operator will need to trust in the mechanism of action of the device. Figure 2 highlights this crucial point to remember while crossing the CTO cap with the Crosser® Catheter. Do not get discouraged if there is a lack of immediate forward movement of the Crosser® Catheter. As Figure 2 shows, the Crosser® Catheter penetrates the CTO cap, which can be seen if EVUS is being used.

With progressive advancement of the Crosser® Catheter into the complex long calcified CTO, the combination of mechanical disruption and cavitation allows the device to cross the disparate parts of the CTO. After successful revascularization of a long, 300-mm CTO, final fluoroscopic angiography was performed with direct runoff to the foot, which continues to be the gold standard during infrainguinal revascularization (Figure 3).