← All decks
Cardiology
Chronic Total Occlusion Percutaneous Coronary Intervention
Built from Cardiovascular Catheterization and Intervention: A Textbook of Coronary, Peripheral, and Structural Heart Disease
What’s inside
12 sections · 114 slides
Defining the chronic total occlusion
- Definition of a coronary chronic total occlusion
- Prevalence of chronic total occlusion
- Collateral circulation and its limits
- Coronary angiographic appearance of occlusive disease
- Attempt rates and technical success in practice
- Barriers to wider adoption of CTO PCI
Rationale for revascularization
- Prognostic impact of an untreated CTO
- Ischemia reduction after successful CTO PCI
- Symptom presentation in CTO patients
- Imaging in asymptomatic left ventricular dysfunction
- Chronic total occlusion and ventricular arrhythmia
- Historical development of CTO intervention
- Coronary stenting in the occluded artery
Evidence base
- Observational evidence for CTO PCI
- OPEN-CTO registry health status outcomes
- Randomised trials of CTO PCI: overall pattern
- Major trials of CTO PCI
- EuroCTO trial
- IMPACTOR-CTO and COMET-CTO trials
- DECISION-CTO trial
- Limitations of the DECISION-CTO trial
- Left ventricular function after CTO PCI
- Obstacles to further randomised trials
- Ongoing randomised trials
Guideline recommendations
- European and American recommendations compared
- Downgrade of the American indication class
- Contemporary guidelines on CTO PCI
- Summary of the indication for CTO PCI
- Outcome gap between expert and non-expert centres
Predicting procedural success
- Role of scoring systems in case selection
- The J-CTO score
- The PROGRESS-CTO score
- Registry-derived technical success scores
- Ellis stratification by proximal cap ambiguity
- CT-RECTOR score from computed tomography
- Limitations of CTO prediction models
- The OPEN-AP score for residual angina
Complications
- Overall complication rates in CTO PCI
- Correlates of complications reported by Ellis
- Classification of coronary perforation
- Management of coronary perforation
- Perforation in patients with prior CABG
- Drainage of loculated pericardial collections
- Side-branch occlusion during CTO PCI
- Recanalization quality and long-term outcome
- Radiation exposure during CTO PCI
- Radiation dose thresholds and monitoring
- Reducing operator radiation dose
Access and guide catheter selection
- Rationale for dual arterial access
- Benefit of dual injection in defining occlusion length
- Hydraulic dissection from antegrade injection
- Options when only ipsilateral collaterals are present
- Ping-pong guide catheter technique
- Guide catheter size selection
- Transradial versus transfemoral access
- Guide catheter length for the retrograde approach
- Coronary interventional equipment
Crossing strategies
- The three major CTO crossing strategies
- Crossing algorithms
- The Global Chronic Total Occlusion Crossing Algorithm
- Role of the microcatheter
- Indications for antegrade wire escalation
- Wire escalation sequence in antegrade crossing
- Use of penetration wires
- Parallel wire technique
- Goal and failure of antegrade wire escalation
- Indications for antegrade dissection and reentry
- Steps of antegrade dissection and reentry
- The knuckled wire technique
- Subintimal tracking and reentry technique
- Dedicated reentry devices
- Successful antegrade dissection and reentry with a reentry device
Retrograde crossing
- Risk profile of the retrograde approach
- Indications for a retrograde strategy
- Choosing the retrograde collateral channel
- Consequences of septal versus epicardial collateral injury
- Intramyocardial hematoma after septal perforation
- Reverse controlled antegrade and retrograde tracking
- Retrograde wire escalation and dissection reentry
Adjuncts and optimization
- Investment procedures for failed crossing
- Roles of intravascular imaging in CTO PCI
- Intravascular ultrasound cross-sectional imaging
- Choice between IVUS and OCT in CTO PCI
- Evidence for imaging-guided stent optimization
- Coronary angiographic result after revascularization
Conclusions
- Advances over the past decade
- What patients should be told before CTO PCI
- Key learning points
- Outstanding questions in the field
References
- References
- References
- References
- References
- References
- References
- References
- References
- References
- References
- References
- Cardiovascular Catheterization and Intervention: A Textbook of Coronary, Peripheral, and Structural Heart Disease
- Join our WhatsApp groups