title: Approach to CTO Intervention: Overview of Techniques.
abstract: Successful percutaneous coronary intervention (PCI) of chronic total occlusions (CTOs) has been associated with significant clinical benefits, but remains technically demanding. Failure to cross the CTO with a guidewire is the most common cause of CTO PCI failure. CTO crossing can be achieved in the antegrade or retrograde direction and can be accomplished by maintaining true lumen position throughout or via subintimal dissection/reentry techniques. A procedural plan should be created prior to the procedure through careful angiographic review of four key parameters: (a) morphology of the proximal occlusion cap; (b) length of the occlusion; (c) quality of the distal vessel and presence of bifurcation at the distal cap; and (d) suitability of collateral circulation for retrograde crossing. Dual coronary injection is recommended in all cases with contralateral collaterals for detailed characterization of the lesion. If one approach fails to progress, a quick transition to the next approach is encouraged to maximize efficacy and efficiency. Procedural complications, including vessel perforation, may occur more frequently in CTO as compared with non-CTO PCI; hence, availability of necessary equipment and expertise in treating such complications are essential.
authors.affiliation: University of Texas Southwestern Medical Center, Dallas, TX, USA.|VA North Texas Health Care System, Dallas, TX, USA.
authors.forename: Aris
authors.initials: A
authors.lastname: Karatasakis
authors.affiliation: University of Texas Southwestern Medical Center, Dallas, TX, USA.|VA North Texas Health Care System, Dallas, TX, USA.
authors.forename: Barbara Anna
authors.initials: BA
authors.lastname: Danek
authors.affiliation: Columbia University Medical Center, New York, NY, USA.
authors.forename: Dimitri
authors.initials: D
authors.lastname: Karmpaliotis
authors.affiliation: Henry Ford Hospital, Detroit, MI, USA.
authors.forename: Khaldoon
authors.initials: K
authors.lastname: Alaswad
authors.affiliation: Mazankowski Heart Institute, Edmonton, AB, Canada.
authors.forename: Minh
authors.initials: M
authors.lastname: Vo
authors.affiliation: San Raffaele Hospital, Milan, Italy.
authors.forename: Mauro
authors.initials: M
authors.lastname: Carlino
authors.affiliation: VA San Diego Healthcare System/University of California San Diego, La Jolla, CA, USA.
authors.forename: Mitul P
authors.initials: MP
authors.lastname: Patel
authors.affiliation: McGill University Health Centre, Montreal, QC, Canada.
authors.forename: Stéphane
authors.initials: S
authors.lastname: Rinfret
authors.affiliation: University of Texas Southwestern Medical Center, Dallas, TX, USA. esbrilakis@gmail.com.|VA North Texas Health Care System, Dallas, TX, USA. esbrilakis@gmail.com.|Minneapolis Heart Institute, 920 E 28th Street #300, Minneapolis, MN, 55407, USA. esbrilakis@gmail.com.
authors.forename: Emmanouil S
authors.initials: ES
authors.lastname: Brilakis
keywords: Antegrade dissection/reentry; Antegrade wire escalation; Chronic total occlusion; Percutaneous coronary intervention; Retrograde; Techniques