Chronic Total Occlusion Crossing Techniques for Infra-Inguinal Peripheral Artery Disease: A Contemporary Guide for Vascular Specialists.

Chronic limb-threatening ischemia (CLTI) represents the most advanced manifestation of peripheral artery disease posing a significant threat to both limb viability and patient survival. Individuals with CLTI frequently exhibit extensive, heavily calcified infrainguinal arterial involvement including chronic total occlusions (CTOs). CTO crossing failure rates can exceed 20% depending on the expertise of the operator. Inadequate revascularization due to unsuccessful CTO crossing can lead to elevated morbidity, major amputation, and increased mortality. As such, contemporary vascular specialists must master CTO crossing techniques for both above-the-knee and below-the-knee disease to optimize procedural success and clinical outcomes. This review outlines and synthesizes the various catheter-based and guidewire strategies currently employed for infrainguinal CTO management.