Guiding Principles for Chronic Total Occlusion Percutaneous Coronary Intervention
Authors: Emmanouil S. Brilakis, Kambis Mashayekhi, Etsuo Tsuchikane, Nidal Abi Rafeh, Khaldoon Alaswad, 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. Nicholas Burke, Heinz Joachim 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. ElGuindy, 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
Journal: Circulation (2019)

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.