Guiding Principles for Chronic Total Occlusion Percutaneous Coronary Intervention.
A Global Expert Consensus Document
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 occlusions (CTOs) are completely occluded coronary arteries with Thrombolysis In Myocardial Infarction 0 flow with an estimated duration of at least 3 months. In recent years, the success rates of CTO percutaneous coronary intervention (PCI) have substantially improved, in concert with the maturation and refinement of the key indications, equipment, and techniques for recanalization of occluded coronary arteries. Global collaboration and sharing of knowledge and techniques have led to the emergence of 7 key principles for the performance of CTO-PCI that can help training, clinical practice, and education in this field (Table 1). This document was conceived during CTO-PCI meetings in 2018 (CTO Summit, Multi-Level CTO, and EuroCTO). An initial document draft was created by a group of CTO-PCI experts from North America, Europe, and Japan. A total of 113 CTO-PCI experts from 56 counties were invited to participate, of whom 101 from 50 countries provided comments and approved the final document.