Guiding Principles for Chronic Total Occlusion Percutaneous Coronary Intervention

Emmanouil S Brilakis¹, Kambis Mashayekhi², Etsuo Tsuchikane³, Nidal Abi Rafeh⁴, Khaldoon Alaswad⁵, Mario Araya⁶, Alexandre Avran⁷, Lorenzo Azzalini⁸, Avtandil M Babunashvili⁹, Baktash Bayani¹⁰, Ravinay Bhindi¹¹, Nicolas Boudou¹², Marouane Boukhris¹³, Nenad Ž Božinović¹⁴, Leszek Bryniarski¹⁵, Alexander Bufe¹⁶, Christopher E Buller¹⁷, M Nicholas Burke¹, Heinz Joachim Büttner², Pedro Cardoso¹⁸, Mauro Carlino⁸, Evald H Christiansen¹⁹, Antonio Colombo²⁰, Kevin Croce²¹, Felix Damas de Los Santos²², Tony De Martini²³, Joseph Dens²⁴, Carlo Di Mario²⁵, Kefei Dou²⁶, Mohaned Egred²⁷, Ahmed M ElGuindy^{28

29}, Javier Escaned³⁰, Sergey Furkalo³¹, Andrea Gagnor³², Alfredo R Galassi³³, Roberto Garbo³⁴, Junbo Ge³⁵, Pravin Kumar Goel³⁶, Omer Goktekin³⁷, Luca Grancini³⁸, J Aaron Grantham³⁹, Colm Hanratty⁴⁰, Stefan Harb⁴¹, Scott A Harding⁴², Jose P S Henriques⁴³, Jonathan M Hill⁴⁴, Farouc A Jaffer⁴⁵, Yangsoo Jang⁴⁶, Risto Jussila⁴⁷, Artis Kalnins⁴⁸, Arun Kalyanasundaram⁴⁹, David E Kandzari⁵⁰, Hsien-Li Kao⁵¹, Dimitri Karmpaliotis⁵², Hussien Heshmat Kassem^{53

54}, Paul Knaapen⁵⁵, Ran Kornowski⁵⁶, Oleg Krestyaninov⁵⁷, A V Ganesh Kumar⁵⁸, Peep Laanmets⁵⁹, Pablo Lamelas^{60

61}, Seung-Whan Lee⁶², Thierry Lefevre⁶³, Yue Li⁶⁴, Soo-Teik Lim⁶⁵, Sidney Lo⁶⁶, William Lombardi⁶⁷, Margaret McEntegart⁶⁸, Muhammad Munawar⁶⁹, José Andrés Navarro Lecaro⁷⁰, Hung M Ngo⁷¹, William Nicholson⁷², Göran K Olivecrona⁷³, Lucio Padilla⁷⁴, Marin Postu⁷⁵, Alexandre Quadros⁷⁶, Franklin Hanna Quesada⁷⁷, Vithala Surya Prakasa Rao⁷⁸, Nicolaus Reifart⁷⁹, Meruzhan Saghatelyan⁸⁰, Ricardo Santiago⁸¹, George Sianos⁸², Elliot Smith⁸³, James C Spratt⁸⁴, Gregg W Stone⁸⁵, Julian W Strange⁸⁶, Khalid Tammam⁸⁷, Imre Ungi⁸⁸, Minh Vo⁸⁹, Vu Hoang Vu⁹⁰, Simon Walsh⁴⁰, Gerald S Werner⁹¹, Jason R Wollmuth⁹², Eugene B Wu⁹³, R Michael Wyman⁹⁴, Bo Xu⁹⁵, Masahisa Yamane⁹⁶, Luiz F Ybarra⁹⁷, Robert W Yeh⁹⁸, Qi Zhang⁹⁹, Stephane Rinfret¹⁰⁰

Affiliations

¹ Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, MN (E.S.B., M.N.B.).
² Department of Cardiology and Angiology II University Heart Center Freiburg Bad Krozingen, Germany (K.M., H.J.B.).
³ Toyohashi Heart Center, Aichi, Japan (E.T.).
⁴ St. George Hospital University Medical Center, Beirut, Lebanon (N.A.R.).
⁵ Henry Ford Hospital, Detroit, MI (K.A.).
⁶ Clínica Alemana and Instituto Nacional del Tórax, Santiago, Chile (M.A.).
⁷ Arnault Tzank Institut St. Laurent Du Var Nice, France (A.A.).
⁸ Interventional Cardiology Division, Cardio-Thoracic-Vascular Department, San Raffaele Scientific Institute, Milan, Italy (L.A., M.C.).
⁹ Department of Cardiovascular Surgery, Center for Endosurgery and Lithotripsy, Moscow, Russian Federation (A.M.B.).
¹⁰ Cardiology Department, Mehr Hospital, Mashhad, Iran (B.B.).
¹¹ Department of Cardiology, Royal North Shore Hospital and Kolling Institute, University of Sydney, Australia (R.B.).
¹² Rangueil University Hospital, Toulouse, France (N.B.).
¹³ Cardiology department, Abderrahment Mami Hospital, Faculty of Medicine of Tunis, University of Tunis El Manar, Tunisia (M.B.).
¹⁴ Department of Interventional Cardiology Clinic for Cardiovascular Diseases University Clinical Center Nis, Serbia (N.Z.B.).
¹⁵ II Department of Cardiology and Cardiovascular Interventions Institute of Cardiology, Jagiellonian University Medical College, Cracow, Poland (L.B.).
¹⁶ Department of Cardiology, Heartcentre Niederrhein, Helios Clinic Krefeld, Krefeld, Germany, Institute for Heart and Circulation Research, University of Cologne, Germany, and University of Witten/Herdecke, Witten, Germany (A.B.).
¹⁷ St. Michael's Hospital, Toronto, ON, Canada (C.E.B.).
¹⁸ Cardiology Department, Santa Maria University Hospital (CHULN), Lisbon Academic Medical Centre (CAML) and Centro Cardiovascular da Universidade de Lisboa (CCUL), Portugal (P.C.).
¹⁹ Department of Cardiology, Aarhus University Hospital, Denmark (E.H.C.).
²⁰ San Raffaele Hospital and Columbus Hospital, Milan, Italy (A.C.).
²¹ Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (K.C.).
²² Interventional Cardiology Department, Instituto Nacional de Cardiología Ignacio Chávez Mexico City, Mexico (F.D.d.l.S.).
²³ SIU School of Medicine, Memorial Medical Center, Springfield, IL (T.D.M.).
²⁴ Department of Cardiology, Hospital Oost-Limburg, Genk, Belgium (J.D.).
²⁵ Structural Interventional Cardiology, Careggi University Hospital, Florence, Italy (C.D.M.).
²⁶ Center for Coronary Heart Disease, State Key Laboratory of Cardiovascular Disease, Fu Wai Hospital, and National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing (K.D.).
²⁷ Freeman Hospital and Newcastle University, Newcastle upon Tyne, United Kingdom (M.E.).
²⁸ Department of Cardiology, Aswan Heart Center, Egypt (A.M.E.).
²⁹ National Heart and Lung Institute, Imperial College London, United Kingdom (A.M.E.).
³⁰ Hospital Clinico San Carlos IDISSC and Universidad Complutense de Madrid, Spain (J.E.).
³¹ Department of Endovascular Surgery and Angiography, National Institute of Surgery and Transplantology of AMS of Ukraine, Kiev (S.F.).
³² Department of Invasive Cardiology, Maria Vittoria Hospital, Turin, Italy (A.G.).
³³ Chair of Cardiology, Department of PROMISE, University of Palermo, Italy (A.R.G.).
³⁴ Director of Interventional Cardiology, San Giovanni Bosco Hospital, Turin, Italy (R.G.).
³⁵ Zhongshan Hospital, Fudan University, Shanghai, China (J.G.).
³⁶ Sanjay Gandhi Post Graduate Institute of Medical Sciences Lucknow, India (P.K.G.).
³⁷ Memorial Hospital, Istanbul, Turkey (O.G.).
³⁸ Centro Cardiologico Monzino, IRCCS, Milan, Italy (L.G.).
³⁹ Saint Luke's Mid America Heart Institute, Kansas City, MO (J.A.G.).
⁴⁰ Belfast Health and Social Care Trust, United Kingdom (C.H., S.W.).
⁴¹ LKH Graz II, Standort West, Kardiologie, Teaching Hospital of the University of Graz, Austria (S.H.).
⁴² Wellington Hospital, Capital and Coast District Health Board, New Zealand (S.A.H.).
⁴³ Academic Medical Centre of the University of Amsterdam, The Netherlands (J.P.S.H.).
⁴⁴ King's College Hospital, London, United Kingdom (J.M.H.).
⁴⁵ Cardiology Division, Massachusetts General Hospital, Boston (F.A.J.).
⁴⁶ Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University Health System, Seoul, South Korea (Y.J.).
⁴⁷ Helsinki Heart Hospital, Finland (R.J.).
⁴⁸ Department of Cardiology, Eastern Clinical University Hospital, Riga, Latvia (A. Kalnins).
⁴⁹ Promed Hospital, Chennai, India (A. Kalyanasundaram).
⁵⁰ Piedmont Heart Institute, Atlanta, GA (D.E.K.).
⁵¹ Department of Internal Medicine, National Taiwan University Hospital, Taipei(H.-L.K.).
⁵² Columbia University, New York (D.K.).
⁵³ Cardiology Department, Kasr Al-Ainy Faculty of Medicine, Cairo University, Egypt(H.H.K.).
⁵⁴ Fujairah Hospital, United Arab Emirates (H.H.K.).
⁵⁵ Department of Cardiology, VU University Medical Center, Amsterdam, The Netherlands (P.K.).
⁵⁶ Department of Cardiology, Rabin Medical Center, Petach Tikva, "Sackler" School of Medicine, Tel Aviv University, Petach Tikva, Israel (R.K.).
⁵⁷ Meshalkin Novosibrisk Research Institute, Russia (O.K.).
⁵⁸ Department of Cardiology, Dr LH Hiranandani Hospital, Mumbai, India (A.V.G.K.).
⁵⁹ North Estonia Medical Center Foundation, Tallinn, Estonia(P. Laanmets).
⁶⁰ Department of Interventional Cardiology and Endovascular Therapeutics, Instituto Cardiovascular de Buenos Aires, Argentina (P. Lamelas).
⁶¹ Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada (P. Lamelas).
⁶² Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea (S.-W.L.).
⁶³ Institut Cardiovasculaire Paris Sud Hopital prive Jacques Cartier, Massy, France (T.L.).
⁶⁴ Department of Cardiology, the First Affiliated Hospital of Harbin Medical University, China (Y.L.).
⁶⁵ Department of Cardiology, National Heart Centre Singapore (S.-T.L.).
⁶⁶ Department of Cardiology, Liverpool Hospital and The University of New South Wales, Sydney, Australia (S.L.).
⁶⁷ University of Washington, Seattle (W.L.).
⁶⁸ Golden Jubilee National Hospital, Glasgow, United Kingdom (M. McEntegart).
⁶⁹ Binawaluya Cardiac Center, Jakarta, Indonesia (M. Munawar).
⁷⁰ Médico Cardiólogo Universitario - Hemodinamista en Hospital de Especialidades Eugenio Espejo y Hospital de los Valles, Ecuador (J.A.N.L.).
⁷¹ Choray Hospital, Vietnam (H.M.N.).
⁷² WellSpan Health System, York, PA (W.N.).
⁷³ Skane University Hospital, University of Lund, Sweden (G.K.O.).
⁷⁴ Department of Interventional Cardiology and Endovascular Therapeutics, ICBA, Instituto Cardiovascular, Buenos Aires, Argentina (L.P.).
⁷⁵ Cardiology Department, University of Medicine and Pharmacy "Carol Davila," Institute of Cardiovascular Diseases "Prof. Dr. C.C. Iliescu," Bucharest, Romania (M.P.).
⁷⁶ Instituto de Cardiologia / Fundação Universitária de Cardiologia - IC/FUC, Porto Alegre, RS - Brazil (A.Q.).
⁷⁷ Interventional Cardiology Department, Clinica Comfamiliar Pereira City, Colombia (F.H.Q.).
⁷⁸ Hyderguda Apollo, Hyderabad, India (V.S.P.R.).
⁷⁹ Department of Cardiology, Main Taunus Heart Institute, Bad Soden, Germany (N.R.).
⁸⁰ Nork-Marash Medical Center, Yerevan, Armenia (M.S.).
⁸¹ Hospital Pavia Santurce, PCI Cardiology Group, San Juan, Puerto Rico (R.S.T.).
⁸² AHEPA University Hospital, Thessaloniki, Greece (G.S.).
⁸³ Department of Cardiology, Barts Heart Centre, St Bartholomew's Hospital, London, United Kingdom (E.S.).
⁸⁴ St George's University Hospital NHS Trust, London, United Kingdom (J.S.).
⁸⁵ Center for Interventional Vascular Therapy, Division of Cardiology, New York-Presbyterian Hospital/Columbia University Medical Center (G.W.S.).
⁸⁶ Department of Cardiology, Bristol Royal Infirmary, United Kingdom (J.W.S.).
⁸⁷ Cardiac Center of Excellence, International Medical Center, Jeddah, Saudi Arabia (K.T.).
⁸⁸ 2nd Department of Internal Medicine and Cardiology Center, University of Szeged, Hungary (I.U.).
⁸⁹ Mazankowski Alberta Heart Institute, Edmonton, AB, Canada (M.V.).
⁹⁰ Interventional Cardiology Department, Heart Center, University Medical Center at Ho Chi Minh City, and University of Medicine and Pharmacy, Vietnam (H.V.).
⁹¹ Medizinische Klinik I Klinikum Darmstadt GmbH, Germany (G.W.).
⁹² Providence Heart and Vascular Institute, Portland, OR (J.R.W.).
⁹³ Prince of Wales Hospital, Hong Kong (E.W.).
⁹⁴ Torrance Memorial Medical Center, CA (R.M.W.).
⁹⁵ Fu Wai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, Beijing (B.X.).
⁹⁶ Saitima St. Luke's International Hospital, Tokyo, Japan (M.Y.).
⁹⁷ London Health Sciences Centre, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada (L.F.Y.).
⁹⁸ Beth Israel Deaconess Medical Center, Boston, MA (R.W.Y.).
⁹⁹ Shanghai East Hospital, Tongji University, China (Q.Z.).
¹⁰⁰ McGill University Health Centre, McGill University, Montreal, QC, Canada (S.R.).

PMID: 31356129
DOI: 10.1161/CIRCULATIONAHA.119.039797

Review

Guiding Principles for Chronic Total Occlusion Percutaneous Coronary Intervention

Emmanouil S Brilakis et al. Circulation. 2019.

. 2019 Jul 30;140(5):420-433.

doi: 10.1161/CIRCULATIONAHA.119.039797. Epub 2019 Jul 29.

Authors

Affiliations

¹ Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, MN (E.S.B., M.N.B.).
² Department of Cardiology and Angiology II University Heart Center Freiburg Bad Krozingen, Germany (K.M., H.J.B.).
³ Toyohashi Heart Center, Aichi, Japan (E.T.).
⁴ St. George Hospital University Medical Center, Beirut, Lebanon (N.A.R.).
⁵ Henry Ford Hospital, Detroit, MI (K.A.).
⁶ Clínica Alemana and Instituto Nacional del Tórax, Santiago, Chile (M.A.).
⁷ Arnault Tzank Institut St. Laurent Du Var Nice, France (A.A.).
⁸ Interventional Cardiology Division, Cardio-Thoracic-Vascular Department, San Raffaele Scientific Institute, Milan, Italy (L.A., M.C.).
⁹ Department of Cardiovascular Surgery, Center for Endosurgery and Lithotripsy, Moscow, Russian Federation (A.M.B.).
¹⁰ Cardiology Department, Mehr Hospital, Mashhad, Iran (B.B.).
¹¹ Department of Cardiology, Royal North Shore Hospital and Kolling Institute, University of Sydney, Australia (R.B.).
¹² Rangueil University Hospital, Toulouse, France (N.B.).
¹³ Cardiology department, Abderrahment Mami Hospital, Faculty of Medicine of Tunis, University of Tunis El Manar, Tunisia (M.B.).
¹⁴ Department of Interventional Cardiology Clinic for Cardiovascular Diseases University Clinical Center Nis, Serbia (N.Z.B.).
¹⁵ II Department of Cardiology and Cardiovascular Interventions Institute of Cardiology, Jagiellonian University Medical College, Cracow, Poland (L.B.).
¹⁶ Department of Cardiology, Heartcentre Niederrhein, Helios Clinic Krefeld, Krefeld, Germany, Institute for Heart and Circulation Research, University of Cologne, Germany, and University of Witten/Herdecke, Witten, Germany (A.B.).
¹⁷ St. Michael's Hospital, Toronto, ON, Canada (C.E.B.).
¹⁸ Cardiology Department, Santa Maria University Hospital (CHULN), Lisbon Academic Medical Centre (CAML) and Centro Cardiovascular da Universidade de Lisboa (CCUL), Portugal (P.C.).
¹⁹ Department of Cardiology, Aarhus University Hospital, Denmark (E.H.C.).
²⁰ San Raffaele Hospital and Columbus Hospital, Milan, Italy (A.C.).
²¹ Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (K.C.).
²² Interventional Cardiology Department, Instituto Nacional de Cardiología Ignacio Chávez Mexico City, Mexico (F.D.d.l.S.).
²³ SIU School of Medicine, Memorial Medical Center, Springfield, IL (T.D.M.).
²⁴ Department of Cardiology, Hospital Oost-Limburg, Genk, Belgium (J.D.).
²⁵ Structural Interventional Cardiology, Careggi University Hospital, Florence, Italy (C.D.M.).
²⁶ Center for Coronary Heart Disease, State Key Laboratory of Cardiovascular Disease, Fu Wai Hospital, and National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing (K.D.).
²⁷ Freeman Hospital and Newcastle University, Newcastle upon Tyne, United Kingdom (M.E.).
²⁸ Department of Cardiology, Aswan Heart Center, Egypt (A.M.E.).
²⁹ National Heart and Lung Institute, Imperial College London, United Kingdom (A.M.E.).
³⁰ Hospital Clinico San Carlos IDISSC and Universidad Complutense de Madrid, Spain (J.E.).
³¹ Department of Endovascular Surgery and Angiography, National Institute of Surgery and Transplantology of AMS of Ukraine, Kiev (S.F.).
³² Department of Invasive Cardiology, Maria Vittoria Hospital, Turin, Italy (A.G.).
³³ Chair of Cardiology, Department of PROMISE, University of Palermo, Italy (A.R.G.).
³⁴ Director of Interventional Cardiology, San Giovanni Bosco Hospital, Turin, Italy (R.G.).
³⁵ Zhongshan Hospital, Fudan University, Shanghai, China (J.G.).
³⁶ Sanjay Gandhi Post Graduate Institute of Medical Sciences Lucknow, India (P.K.G.).
³⁷ Memorial Hospital, Istanbul, Turkey (O.G.).
³⁸ Centro Cardiologico Monzino, IRCCS, Milan, Italy (L.G.).
³⁹ Saint Luke's Mid America Heart Institute, Kansas City, MO (J.A.G.).
⁴⁰ Belfast Health and Social Care Trust, United Kingdom (C.H., S.W.).
⁴¹ LKH Graz II, Standort West, Kardiologie, Teaching Hospital of the University of Graz, Austria (S.H.).
⁴² Wellington Hospital, Capital and Coast District Health Board, New Zealand (S.A.H.).
⁴³ Academic Medical Centre of the University of Amsterdam, The Netherlands (J.P.S.H.).
⁴⁴ King's College Hospital, London, United Kingdom (J.M.H.).
⁴⁵ Cardiology Division, Massachusetts General Hospital, Boston (F.A.J.).
⁴⁶ Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University Health System, Seoul, South Korea (Y.J.).
⁴⁷ Helsinki Heart Hospital, Finland (R.J.).
⁴⁸ Department of Cardiology, Eastern Clinical University Hospital, Riga, Latvia (A. Kalnins).
⁴⁹ Promed Hospital, Chennai, India (A. Kalyanasundaram).
⁵⁰ Piedmont Heart Institute, Atlanta, GA (D.E.K.).
⁵¹ Department of Internal Medicine, National Taiwan University Hospital, Taipei(H.-L.K.).
⁵² Columbia University, New York (D.K.).
⁵³ Cardiology Department, Kasr Al-Ainy Faculty of Medicine, Cairo University, Egypt(H.H.K.).
⁵⁴ Fujairah Hospital, United Arab Emirates (H.H.K.).
⁵⁵ Department of Cardiology, VU University Medical Center, Amsterdam, The Netherlands (P.K.).
⁵⁶ Department of Cardiology, Rabin Medical Center, Petach Tikva, "Sackler" School of Medicine, Tel Aviv University, Petach Tikva, Israel (R.K.).
⁵⁷ Meshalkin Novosibrisk Research Institute, Russia (O.K.).
⁵⁸ Department of Cardiology, Dr LH Hiranandani Hospital, Mumbai, India (A.V.G.K.).
⁵⁹ North Estonia Medical Center Foundation, Tallinn, Estonia(P. Laanmets).
⁶⁰ Department of Interventional Cardiology and Endovascular Therapeutics, Instituto Cardiovascular de Buenos Aires, Argentina (P. Lamelas).
⁶¹ Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada (P. Lamelas).
⁶² Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea (S.-W.L.).
⁶³ Institut Cardiovasculaire Paris Sud Hopital prive Jacques Cartier, Massy, France (T.L.).
⁶⁴ Department of Cardiology, the First Affiliated Hospital of Harbin Medical University, China (Y.L.).
⁶⁵ Department of Cardiology, National Heart Centre Singapore (S.-T.L.).
⁶⁶ Department of Cardiology, Liverpool Hospital and The University of New South Wales, Sydney, Australia (S.L.).
⁶⁷ University of Washington, Seattle (W.L.).
⁶⁸ Golden Jubilee National Hospital, Glasgow, United Kingdom (M. McEntegart).
⁶⁹ Binawaluya Cardiac Center, Jakarta, Indonesia (M. Munawar).
⁷⁰ Médico Cardiólogo Universitario - Hemodinamista en Hospital de Especialidades Eugenio Espejo y Hospital de los Valles, Ecuador (J.A.N.L.).
⁷¹ Choray Hospital, Vietnam (H.M.N.).
⁷² WellSpan Health System, York, PA (W.N.).
⁷³ Skane University Hospital, University of Lund, Sweden (G.K.O.).
⁷⁴ Department of Interventional Cardiology and Endovascular Therapeutics, ICBA, Instituto Cardiovascular, Buenos Aires, Argentina (L.P.).
⁷⁵ Cardiology Department, University of Medicine and Pharmacy "Carol Davila," Institute of Cardiovascular Diseases "Prof. Dr. C.C. Iliescu," Bucharest, Romania (M.P.).
⁷⁶ Instituto de Cardiologia / Fundação Universitária de Cardiologia - IC/FUC, Porto Alegre, RS - Brazil (A.Q.).
⁷⁷ Interventional Cardiology Department, Clinica Comfamiliar Pereira City, Colombia (F.H.Q.).
⁷⁸ Hyderguda Apollo, Hyderabad, India (V.S.P.R.).
⁷⁹ Department of Cardiology, Main Taunus Heart Institute, Bad Soden, Germany (N.R.).
⁸⁰ Nork-Marash Medical Center, Yerevan, Armenia (M.S.).
⁸¹ Hospital Pavia Santurce, PCI Cardiology Group, San Juan, Puerto Rico (R.S.T.).
⁸² AHEPA University Hospital, Thessaloniki, Greece (G.S.).
⁸³ Department of Cardiology, Barts Heart Centre, St Bartholomew's Hospital, London, United Kingdom (E.S.).
⁸⁴ St George's University Hospital NHS Trust, London, United Kingdom (J.S.).
⁸⁵ Center for Interventional Vascular Therapy, Division of Cardiology, New York-Presbyterian Hospital/Columbia University Medical Center (G.W.S.).
⁸⁶ Department of Cardiology, Bristol Royal Infirmary, United Kingdom (J.W.S.).
⁸⁷ Cardiac Center of Excellence, International Medical Center, Jeddah, Saudi Arabia (K.T.).
⁸⁸ 2nd Department of Internal Medicine and Cardiology Center, University of Szeged, Hungary (I.U.).
⁸⁹ Mazankowski Alberta Heart Institute, Edmonton, AB, Canada (M.V.).
⁹⁰ Interventional Cardiology Department, Heart Center, University Medical Center at Ho Chi Minh City, and University of Medicine and Pharmacy, Vietnam (H.V.).
⁹¹ Medizinische Klinik I Klinikum Darmstadt GmbH, Germany (G.W.).
⁹² Providence Heart and Vascular Institute, Portland, OR (J.R.W.).
⁹³ Prince of Wales Hospital, Hong Kong (E.W.).
⁹⁴ Torrance Memorial Medical Center, CA (R.M.W.).
⁹⁵ Fu Wai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, Beijing (B.X.).
⁹⁶ Saitima St. Luke's International Hospital, Tokyo, Japan (M.Y.).
⁹⁷ London Health Sciences Centre, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada (L.F.Y.).
⁹⁸ Beth Israel Deaconess Medical Center, Boston, MA (R.W.Y.).
⁹⁹ Shanghai East Hospital, Tongji University, China (Q.Z.).
¹⁰⁰ McGill University Health Centre, McGill University, Montreal, QC, Canada (S.R.).

PMID: 31356129
DOI: 10.1161/CIRCULATIONAHA.119.039797

Abstract

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.

Keywords: coronary occlusion; methods; outcome; percutaneous coronary intervention; treatment.

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Guiding Principles for Chronic Total Occlusion Percutaneous Coronary Intervention

Affiliations

Guiding Principles for Chronic Total Occlusion Percutaneous Coronary Intervention

Authors

Affiliations

Abstract

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LinkOut - more resources

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