{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,7,31]],"date-time":"2026-07-31T16:25:56Z","timestamp":1785515156064,"version":"3.56.0"},"reference-count":24,"publisher":"Wiley","issue":"3","license":[{"start":{"date-parts":[[2025,6,29]],"date-time":"2025-06-29T00:00:00Z","timestamp":1751155200000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by-nc\/4.0\/"},{"start":{"date-parts":[[2025,6,29]],"date-time":"2025-06-29T00:00:00Z","timestamp":1751155200000},"content-version":"tdm","delay-in-days":0,"URL":"http:\/\/doi.wiley.com\/10.1002\/tdm_license_1.1"}],"content-domain":{"domain":["onlinelibrary.wiley.com"],"crossmark-restriction":true},"short-container-title":["Cathet Cardio Intervent"],"published-print":{"date-parts":[[2025,9]]},"abstract":"<jats:title>ABSTRACT<\/jats:title>\n                  <jats:sec>\n                    <jats:title>Background<\/jats:title>\n                    <jats:p>Endovascular therapy (EVT) for chronic total occlusions (CTOs) in patients with critical limb\u2010threatening ischemia (CLTI) remains technically challenging, particularly in infrapopliteal lesions. Direct injection in occlusive lesions (DIOL) fashion is a novel adjunctive strategy that utilizes hydraulic contrast injection through a microcatheter to facilitate guidewire passage by visualizing the vascular pathway. However, its clinical efficacy remains limited.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Aims<\/jats:title>\n                    <jats:p>This study aimed to evaluate the periprocedural outcomes of DIOL\u2010assisted EVT for infrapopliteal and inframalleolar CTOs in patients with CLTI.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>This retrospective, single\u2010center study enrolled 102 patients (102 limbs) with CLTI who underwent DIOL\u2010assisted EVT between October 2018 and 2024. The primary outcome was successful guidewire crossing. Secondary outcomes included technical success, 30\u2010day mortality, major amputation, and target lesion revascularization (TLR).<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>All target lesions were classified as GLASS stage 4 CTOs, with bilateral calcification in 49% of cases. The mean patient age was 77.0 years; 69% were non\u2010ambulatory, and 23% were on hemodialysis. A total of 76% of patients presented with Rutherford stage 5\u20136 wounds. DIOL was employed in 91% of infrapopliteal and 22% of inframalleolar lesions. The guidewire crossing and technical success rates were 98% and 95%, respectively. Guidewire perforation occurred in 7% of cases with no major bleeding complications. The 30\u2010day mortality, major amputation, and TLR rates were 5%, 0%, and 11%, respectively.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>DIOL is a useful adjunctive strategy in complex CTOs, potentially facilitating guidewire passage and contributing to procedural success in infrapopliteal and inframalleolar revascularization. Further studies are warranted to validate and standardize its application.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1002\/ccd.31729","type":"journal-article","created":{"date-parts":[[2025,6,30]],"date-time":"2025-06-30T02:29:52Z","timestamp":1751250592000},"page":"1610-1618","update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":2,"title":["Efficacy of Direct Injection in Occlusive Lesion (DIOL) Fashion for Infrapopliteal and Inframalleolar Chronic Total Occlusions"],"prefix":"10.1002","volume":"106","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-2116-2178","authenticated-orcid":false,"given":"Takuya","family":"Haraguchi","sequence":"first","affiliation":[{"name":"Department of Cardiology Asia Medical Group, Sapporo Heart Center, Sapporo Cardio Vascular Clinic Sapporo 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