Frontrunner: ‘Crossing the finish “lesion” by a nose’

Chronic mesenteric ischemia (CMI) has the potential to be life threatening and ultimately may result in death secondary to bowel infarction or inanition. Fortunately, its incidence is quite low; however, as a result, there is a paucity of data and limited experience among the cadre of vascular physicians responsible for the management of these challenging patients. The optimal treatment remains elusive and poorly defined, such as the means of revascularization (endovascular versus open repair), type of bypass procedure, and number of vessels to be revascularized, where all outstanding issues continue to be debated amongst the physicians [1]. The underlying poor substrate and systemic nature of atherosclerosis associated with the multiple comorbid risk factors rampant in these patients make any surgical intervention challenging to say the least. As a result of the tremendous proliferation of endovascular therapeutic options available to the experienced vascular interventionalist, its role enjoys tremendous appeal for patients because of its being less invasive, readily repeated, abbreviated length of stay, lower morbidity and mortality, thus incurring less hospital costs and sparing vessels for future grafts if failure occurs [2]. Despite the laudable technical success rates reported for the recanalization of lower extremity chronic total occlusions employing conventional guidewires and catheter combinations in the greater than 80% range, it dwarfs the successful traversal rate of greater than 95% in arterial stenoses. The multiple lesion characteristics that influence the success rate of endovascular treatment for chronic total occlusions (CTO) are; age of the occlusion, lesion length and its morphology, presence of calcification and collaterals, and degree of distal flow [3]. Consequently, a renewed enthusiasm has piqued a keen interest in the development of novel devices and techniques to facilitate percutaneous recanalization of these recalcitrant CTOs. These include controlled blunt microdissection as well as two re-entry total occlusion catheters (e.g., Outback and Pioneer) [4–6]. In this issue of the Journal, Ayres et al. [7] describe the first reported case of blunt microdissection using a Frontrunner XP CTO Catheter to facilitate the successful revascularization—PTA and stenting of an occluded celiac trunk in a patient stricken with severe chronic mesenteric ischemia. The patient was a 40-yearold male with a 4-year history of symptoms commensurate with intestinal ischemia who had previously undergone an unsuccessful vascular intervention of his chronically occluded celiac artery, in part, because of the inability to cross the occlusion with conventional techniques at the time of initial presentation. Subsequently, he was lost to follow-up, but ultimately presented with intractable and lifestyle-limiting intestinal angina 4 years later despite the self-administration of narcotics, methamphetamines, and anticoagulation, which was prescribed at the time of discharge from his initial hospital course. The patient eventually underwent successful endovascular intervention by an experienced vascular medicine specialist, after apparently refusing surgery. Further complicating the technical complexity of the procedure in addition to a 4þ year old total occlusion, angiography demonstrated an anatomic variant, with a celiomesenteric trunk, which bifurcated into the celiac axis and superior mesenteric artery (SMA), both of which were occluded over a length of 2 cm where it reconstituted via collaterals. The inferior mesenteric artery (IMA) was not identified, and therefore, the primary source of perfusion to the gut was through a phrenic artery, which arose from the right renal artery and robust collaterals from the proximal celiac trunk. Reminiscent of the initial attempt to recanalize the occluded artery, the operators were unable to successfully cross the lesion and therefore employed the Frontrunner microdissection device and were able to