Guiding Principles for Chronic Total Occlusion Percutaneous Coronary Intervention


Emmanouil S. Brilakis
Kambis Mashayekhi
Etsuo Tsuchikane
Nidal Abi Rafeh
Khaldoon Alaswad, Henry Ford HealthFollow
Mario Araya
Alexandre Avran
Lorenzo Azzalini
Avtandil M. Babunashvili
Baktash Bayani
Ravinay Bhindi
Nicolas Boudou
Marouane Boukhris
Nenad Ž. Božinović
Leszek Bryniarski
Alexander Bufe
Christopher E. Buller
M N. Burke
Heinz J. Büttner
Pedro Cardoso
Mauro Carlino
Evald H Christiansen
Antonio Colombo
Kevin Croce
Felix Damas de Los Santos
Tony De Martini
Joseph Dens
Carlo Di Mario
Kefei Dou
Mohaned Egred
Ahmed M. El-Guindy
Javier Escaned
Sergey Furkalo
Andrea Gagnor
Alfredo R Galassi
Roberto Garbo
Junbo Ge
Pravin Kumar Goel
Omer Goktekin
Luca Grancini
J Aaron Grantham
Colm Hanratty
Stefan Harb
Scott A Harding
Jose P S Henriques
Jonathan M Hill
Farouc A Jaffer
Yangsoo Jang
Risto Jussila
Artis Kalnins
Arun Kalyanasundaram
David E Kandzari
Hsien-Li Kao
Dimitri Karmpaliotis
Hussien Heshmat Kassem
Paul Knaapen
Ran Kornowski
Oleg Krestyaninov
A V Ganesh Kumar
Peep Laanmets
Pablo Lamelas
Seung-Whan Lee
Thierry Lefevre
Yue Li
Soo-Teik Lim
Sidney Lo
William Lombardi
Margaret McEntegart
Muhammad Munawar
José Andrés Navarro Lecaro
Hung M Ngo
William Nicholson
Göran K Olivecrona
Lucio Padilla
Marin Postu
Alexandre Quadros
Franklin Hanna Quesada
Vithala Surya Prakasa Rao
Nicolaus Reifart
Meruzhan Saghatelyan
Ricardo Santiago
George Sianos
Elliot Smith
James C Spratt
Gregg W Stone
Julian W Strange
Khalid Tammam
Imre Ungi
Minh Vo
Vu Hoang Vu
Simon Walsh
Gerald S Werner
Jason R Wollmuth
Eugene B Wu
R Michael Wyman
Bo Xu
Masahisa Yamane
Luiz F Ybarra
Robert W Yeh
Qi Zhang
Stephane Rinfret

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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.

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