Latest developments in chronic total occlusion percutaneous coronary intervention

ABSTRACT

Introduction

Chronic Total Occlusion Percutaneous Coronary Intervention (CTO PCI) is now performed with high success rates and acceptable complication rates.

Areas covered

We describe recent clinical and technological developments in CTO PCI from 2018 to 2020.

Expert opinion

After publication of six randomized controlled trials, improving patient symptoms remains the principal indication for CTO PCI. Although good outcomes can be achieved with CTO PCI at experienced centers, success rates are significantly lower at less experienced centers, despite increased use in CTO crossing algorithms and development of novel and improved equipment and techniques.

KEYWORDS:

• Chronic total occlusion
• coronary artery disease
• coronary occlusion percutaneous coronary intervention
• stent

Article highlights

• Symptom improvement remains the key indication for CTO PCI. Whether CTO PCI could potentially improve hard outcomes such as death and myocardial infarction remains controversial and is currently only supported by observational, retrospective data.

• Although good outcomes can be achieved with CTO PCI at experienced centers (success: 85–90% with ≈3% complication rate) success rates are significantly lower at less experienced centers. Improvements in education, and increased experience with available equipment and techniques are still needed to bridge this gap.

• There is convergence in CTO crossing techniques and algorithms used around the world. It is widely accepted that outcomes of CTO PCI are optimal with dual injection and careful angiographic review, use of microcatheters to support the guidewires, use of all available crossing strategies, and prompt changes in techniques and equipment if the initially selected strategy fails.

• Introduction of new equipment, including new specialized microcatheters and guidewires with enhanced properties, will continue to benefit CTO operators worldwide.

• Coronary computed tomography angiography is increasingly being used for pre-and intra-procedural guidance in more complex cases.

• Use of radial access for CTO PCI has significantly increased, with a radial-femoral approach currently being the most common access configuration.

• Finally, there is increasing awareness and implementation of stent optimization, including the appropriate use of imaging techniques, during CTO PCI. Stent optimization will reduce both acute and the long-term adverse events.

Declaration of interest

AH Gershlick received travel sponsorship and speaker’s fees from Abbott Vascular and Medtronic. S Rinfret received consultant honoraria from Boston Scientific, Teleflex, Abbott Vascular, Abiomed, and SoundBite Medical. A Avran received proctoring income from Boston Scientific, Abbott Vascular, Terumo, Biotronik, and Biosensors. M Egred received proctor income for ELCA, honoraria and speaker fees from Philips, Abbott Vascular, Boston Scientific, Vascular Perspectives, Biosensors, Biotronik, and AstraZeneca. S Garcia received consulting fees from Medtronic. MN Burke received consulting and speaker honoraria from Abbott Vascular and Boston Scientific. ES Brilakis received consulting/speaker honoraria from Abbott Vascular, American Heart Association (associate editor Circulation), Biotronik, Boston Scientific, Cardiovascular Innovations Foundation (Board of Directors), CSI, Elsevier, GE Healthcare, InfraRedx, Medtronic, Siemens, and Teleflex; research support from Regeneron and Siemens. Shareholder: MHI Ventures. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose. 

Additional information

Funding

This paper was not funded.