State-of-the-Art Paper
A Percutaneous Treatment Algorithm for Crossing Coronary Chronic Total Occlusions

https://doi.org/10.1016/j.jcin.2012.02.006Get rights and content
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Coronary chronic total occlusions (CTOs) are frequently identified during coronary angiography and remain the most challenging lesion group to treat. Patients with CTOs are frequently left unrevascularized due to perceptions of high failure rates and technical complexity even if they have symptoms of coronary disease or ischemia. In this review, the authors describe a North American contemporary approach for percutaneous coronary interventions for CTO. Two guide catheters are placed to facilitate seamless transition between antegrade wire–based, antegrade dissection re-entry–based, and retrograde (wire or dissection re-entry) techniques, the “hybrid” interventional strategy. After dual coronary injection is performed, 4 angiographic parameters are assessed: 1) clear understanding of location of the proximal cap using angiography or intravascular ultrasonography; 2) lesion length; 3) presence of branches, as well as size and quality of the target vessel at the distal cap; and 4) suitability of collaterals for retrograde techniques. On the basis of these 4 characteristics, an initial strategy and rank order hierarchy for technical approaches is established. Radiation exposure, contrast utilization, and procedure time are monitored throughout the procedure, and thresholds are established for intraprocedural strategy conversion to maximize safety, efficiency, and effectiveness.

Key Words

chronic total occlusion
devices
percutaneous coronary intervention

Abbreviations and Acronyms

CART
controlled antegrade and retrograde tracking
CTO
chronic total occlusion
LaST
limited antegrade subintimal tracking
OTW
over the wire
PCI
percutaneous coronary intervention
RAO
right anterior oblique

Cited by (0)

Dr. Brilakis has received speaker honoraria from St. Jude Medical and Terumo; research support from Abbott Vascular and InfraReDx; and his spouse is an employee of Medtronic. Dr. Grantham has received grants and honoraria from Abbott Vascular, BridgePoint Medical, and Vascular Solutions, all paid directly to Saint Luke's Hospital Foundation. Dr. Rinfret has received honoraria for proctorship from Abbott Vascular and BridgePoint Medical and honoraria for conference from Terumo and BridgePoint Medical. Dr. Wyman is a consultant/honoraria from Abbott Vascular, BridgePoint Medical, Terumo, and Boston Scientific; and has equity in BridgePoint Medical. Dr. Burke is a consultant for BridgePoint Medical and Terumo Medical. Dr. Karmpaliotis is on the speaker's bureau of Abbott Vascular and Medtronic; and is a consultant for BridgePoint Medical. Dr. Lembo is on the speaker's bureau of Medtronic; he is on the advisory board of Abbott Vascular and Medtronic; and he is a proctor for BridgePoint Medical. Dr. Pershad has received speaker honoraria from Medtronic and Abbott Vascular; and consulting fees from BridgePoint Medical. Dr. Kandzari's institution (Piedmont Heart Institute) has received educational grants from BridgePoint Medical; and he has received research/grant support from and is a consultant for Abbott Vascular, Medtronic CardioVascular, and Boston Scientific. Dr. Buller is a consultant for Abbott Vascular and AstraZeneca. Dr. DeMartini is a consultant for and on the speaker's bureau of Abbott Vascular. Dr. Lombardi is a consultant for Abbott Vascular, BridgePoint Medical, and Medtronic; has received speaker honoraria from Abbott Vascular, Medtronic, Boston Scientific, and Terumo (all funds paid to his institution - PeaceHealth); and has equity in BridgePoint Medical. Dr. Thompson is a consultant for Abbott Vascular, BridgePoint Medical, Terumo, and Volcano; and has equity in BridgePoint Medical.