Guiding Principles for Chronic Total Occlusion Percutaneous Coronary Intervention

Abstract

Outcomes of chronic total occlusion (CTO) percutaneous coronary intervention (PCI) have improved because of advancements in equipment and techniques. With global collaboration and knowledge sharing, we have identified 7 common principles that are widely accepted as best practices for CTO-PCI. 1. Ischemic symptom improvement is the primary indication for CTO-PCI. 2. Dual coronary angiography and in-depth and structured review of the angiogram (and, if available, coronary computed tomography angiography) are key for planning and safely performing CTO-PCI. 3. Use of a microcatheter is essential for optimal guidewire manipulation and exchanges. 4. Antegrade wiring, antegrade dissection and reentry, and the retrograde approach are all complementary and necessary crossing strategies. Antegrade wiring is the most common initial technique, whereas retrograde and antegrade dissection and reentry are often required for more complex CTOs. 5. If the initially selected crossing strategy fails, efficient change to an alternative crossing technique increases the likelihood of eventual PCI success, shortens procedure time, and lowers radiation and contrast use. 6. Specific CTO-PCI expertise and volume and the availability of specialized equipment will increase the likelihood of crossing success and facilitate prevention and management of complications, such as perforation. 7. Meticulous attention to lesion preparation and stenting technique, often requiring intracoronary imaging, is required to ensure optimum stent expansion and minimize the risk of short- and long-term adverse events. These principles have been widely adopted by experienced CTO-PCI operators and centers currently achieving high success and acceptable complication rates. Outcomes are less optimal at less experienced centers, highlighting the need for broader adoption of the aforementioned 7 guiding principles along with the development of additional simple and safe CTO crossing and revascularization strategies through ongoing research, education, and training.

Chronic total occlusion recanalization for myocardial infarction

“…However, CTOs in prior CABG patients can be challenging to treat as they often have blunt stump, severe tortuosity, and severe calcification, likely because the distal cap is exposed to systemic arterial pressure . As a result, CTO PCI is best performed as a planned procedure and not ad hoc, as was done in our case. If feasible, “staged SVG revascularization” is an alternative approach: the culprit SVG lesion is initially treated during the acute phase of MI, restoring flow to the supplied myocardium.…”

Retrograde approach for percutaneous treatment of chronic total occlusions of coronary arteries

“…2 Successful percutaneous CTO recanalization may reduce angina symptoms, and improve quality of life and left ventricular systolic function. 2,[4][5][6][7][8] The selection process for the initial and subsequent percutaneous crossing strategies depends on the lesion characteristics and the local equipment availability, along with the operator expertise. Currently, there are various algorithms that can help select the best crossing strategy, such as the hybrid, 9 Asia Pacific, 10 and EUROCTO 11 algorithms.…”

“…As initial strategy, the antegrade approach, particularly antegrade wire escalation, is preferred to retrograde crossing, given the higher risk of complications with the retrograde approach, 12 and the need for antegrade lesion preparation, even when the retrograde approach is eventually required. 4,6 Usually, antegrade wire escalation is used in cases with non-ambiguous proximal cap, good distal landing zone and short lesions (<20mm); cases with ambiguous proximal cap and or long lesion length are explored with antegrade dissection techniques. 6,13 Providing that there are coronary collaterals deemed negotiable for crossing (so-called interventional collaterals), a retrograde approach is more desirable in ostial CTO or with an ambiguous proximal cap as well as in CTO with long and tortuous lesions, CTO with diseased landing zone or with distal bifurcated caps.…”

Chronic total occlusion percutaneous coronary intervention failure: Learning from failure

“…It was clearly the operator. Several series from experienced operators and centers have demonstrated similarly high success rates of 85–90%, in contrast to approximately 60% success rates reported by general PCI registries . CTO PCI is a highly specialized procedure that requires dedicated expertise and should be performed by operators and centers that have invested and continue to invest the time and energy required to develop the necessary skills.…”

“…The retrograde approach should, therefore, be used cautiously, ideally when there are no antegrade crossing options, or antegrade crossing options have failed. CTO PCI operators should always remain vigilant for development of a complication and be ready to treat them having access to the necessary equipment (such as covered stents and coils) and expertise on how to use this equipment . Understanding when to “push the envelope” and when not is key: a failed procedure is in most cases preferable to a complication.…”