Global Chronic Total Occlusion Crossing Algorithm
Authors: Eugene B. Wu, Emmanouil S. Brilakis, Kambis Mashayekhi, Etsuo Tsuchikane, Khaldoon Alaswad, Mario Araya, Alexandre Avran, Lorenzo Azzalini, Avtandil M. Babunashvili, Baktash Bayani, Michael Behnes, Ravinay Bhindi, Nicolas Boudou, Marouane Boukhris, Nenad Z. Bozinovic, Leszek Bryniarski, Alexander Bufe, Christopher E. Buller, M. Nicholas Burke, Achim Buttner, Pedro Cardoso, Mauro Carlino, Ji-Yan Chen, Evald Hoej Christiansen, Antonio Colombo, Kevin Croce, Felix Damas de los Santos, Tony de Martini, Joseph Dens, Carlo di Mario, Kefei Dou, Mohaned Egred, Basem Elbarouni, Ahmed M. ElGuindy, Javier Escaned, Sergey Furkalo, Andrea Gagnor, Alfredo R. Galassi, Roberto Garbo, Gabriele Gasparini, Junbo Ge, Lei Ge, Pravin Kumar Goel, Omer Goktekin, Nieves Gonzalo, Luca Grancini, Allison Hall, Franklin Leonardo Hanna Quesada, Colm Hanratty, Stefan Harb, Scott A. Harding, Raja Hatem, Jose P.S. Henriques, David Hildick-Smith, Jonathan M. Hill, Angela Hoye, Wissam Jaber, Farouc A. Jaffer, Yangsoo Jang, Risto Jussila, Artis Kalnins, Arun Kalyanasundaram, David E. Kandzari, Hsien-Li Kao, Dimitri Karmpaliotis, Hussien Heshmat Kassem, Jaikirshan Khatri, Paul Knaapen, Ran Kornowski, Oleg Krestyaninov, A.V. Ganesh Kumar, Pablo Manuel Lamelas, Seung-Whan Lee, Thierry Lefevre, Raymond Leung, Yu Li, Yue Li, Soo-Teik Lim, Sidney Lo, William Lombardi, Anbukarasi Maran, Margaret McEntegart, Jeffrey Moses, Muhammad Munawar, Andres Navarro, Hung M. Ngo, William Nicholson, Anja Oksnes, Goran K. Olivecrona, Lucio Padilla, Mitul Patel, Ashish Pershad, Marin Postu, Jie Qian, Alexandre Quadros, Nidal Abi Rafeh, Truls Råmunddal, Vithala Surya Prakasa Rao, Nicolaus Reifart, Robert F. Riley, Stephane Rinfret, Meruzhan Saghatelyan, George Sianos, Elliot Smith, Anthony Spaedy, James Spratt, Gregg Stone, Julian W. Strange, Khalid O. Tammam, Craig A. Thompson, Aurel Toma, Jennifer A. Tremmel, Ricardo Santiago Trinidad, Imre Ungi, Minh Vo, Vu Hoang Vu, Simon Walsh, Gerald Werner, Jaroslaw Wojcik, Jason Wollmuth, Bo Xu, Masahisa Yamane, Luiz F. Ybarra, Robert W. Yeh, Qi Zhang
Journal: Journal of the American College of Cardiology (2021)

The authors developed a global chronic total occlusion crossing algorithm following 10 steps: 1) dual angiography; 2) careful angiographic review focusing on proximal cap morphology, occlusion segment, distal vessel quality, and collateral circulation; 3) approaching proximal cap ambiguity using intravascular ultrasound, retrograde, and move-the-cap techniques; 4) approaching poor distal vessel quality using the retrograde approach and bifurcation at the distal cap by use of a dual-lumen catheter and intravascular ultrasound; 5) feasibility of retrograde crossing through grafts and septal and epicardial collateral vessels; 6) antegrade wiring strategies; 7) retrograde approach; 8) changing strategy when failing to achieve progress; 9) considering performing an investment procedure if crossing attempts fail; and 10) stopping when reaching high radiation or contrast dose or in case of long procedural time, occurrence of a serious complication, operator and patient fatigue, or lack of expertise or equipment. This algorithm can improve outcomes and expand discussion, research, and collaboration.