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Review
. 2025 Jun;18(6):e014801.
doi: 10.1161/CIRCINTERVENTIONS.124.014801. Epub 2025 Apr 14.

Chronic Total Occlusion Percutaneous Coronary Intervention: Present and Future

Emmanouil S Brilakis  1 , Yader Sandoval  1 , Lorenzo Azzalini  2 , Gregor Leibundgut  3 , Roberto Garbo  4 , Allison B Hall  5 , Rhian E Davies  6 , Kambis Mashayekhi  7 , Masahisa Yamane  8 , Alexandre Avran  9 , Jaikirshan J Khatri  10 , Khaldoon Alaswad  11 , Farouc A Jaffer  12 , Stephane Rinfret  13
Affiliations
Review

Chronic Total Occlusion Percutaneous Coronary Intervention: Present and Future

Emmanouil S Brilakis et al. Circ Cardiovasc Interv. 2025 Jun.

Abstract

Chronic total occlusion percutaneous coronary intervention has evolved into a subspecialty of interventional cardiology. Using a variety of antegrade and retrograde techniques, experienced operators currently achieve success rates of 85% to 90%, with an incidence of major periprocedural complications of ≈2% to 3%. Several developments in equipment (new microcatheters and guidewires, novel reentry devices), imaging (computed tomography angiography guidance, intravascular imaging for reentry), techniques (intraocclusion contrast injection, advanced subintimal tracking and reentry), and artificial intelligence (automated computed tomography image analysis and prediction of the likelihood of crossing success with various techniques) could further improve outcomes. Global collaboration and rapid dissemination of new developments accelerate the pace of progress. While innovation is exciting and necessary, adhering to the basic principles of chronic total occlusion percutaneous coronary intervention (such as continual assessment of risks and benefits, meticulous angiographic review, and use of dual injection) remains critical for achieving optimal patient outcomes.

Keywords: artificial intelligence; cardiology; coronary occlusion; incidence; risk assessment.

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Conflict of interest statement

Dr Brilakis: Consulting/speaker honoraria from Abbott Vascular, American Heart Association (Associate Editor, Circulation), Biotronik, Boston Scientific, Cardiovascular Innovations Foundation (Board of Directors), Cordis, CSI, Elsevier, GE Healthcare, Haemonetics, IMDS, Medtronic, SIS Medical, Teleflex, and Orbus Neich; research support: Boston Scientific, GE Healthcare; owner, Hippocrates LLC; shareholder: LifeLens Technologies, Inc, MHI Ventures, Cleerly Health, Stallion Medical, TrueVue, Inc. Dr Sandoval: Consultant and speaker honoraria: Abbott, Roche Diagnostics, Philips, Zoll, GE Healthcare, CathWorks, HeartFlow, Cleerly. Dr Azzalini: Consulting fees from Teleflex, Abiomed, GE Healthcare, Reflow Medical, Shockwave, and Cardiovascular Systems, Inc; received a research grant from Abiomed; serves on the advisory board of Abiomed and GE Healthcare; owns equity in Reflow Medical. Dr Leibundgut: Received an unrestricted educational grant from Abbott Vascular, Biotronik, and Cordis; received speaker honoraria from Cordis, Terumo, BBraun, Shockwave, Teleflex, and Medtronic; serves as proctor for CTO-PCI, suture-based PFO closure, and rotational atherectomy. Dr Garbo: Consultant/proctorship from Asahi, Boston Scientific, Ivascular, IMDS, Teleflex, Terumo, Philips. Dr Hall: Speaker/honoraria from Teleflex, Shockwave Medical. Dr Davies: Speaking honoraria from Abiomed, Asahi Intecc, Boston Scientific, Medtronic, Shockwave, and Teleflex; serves on advisory boards for Abiomed, Avinger, Boston Scientific, Medtronic, Rampart, and Shockwave. Dr Mashayekhi: Consulting/speaker/proctoring honoraria from Abbott Vascular, Abiomed, Asahi Intecc, AstraZeneca, Biotronik, Boston Scientific, Cardinal Health, Daiichi Sankyo, Medtronic, Orbus Neich, Shockwave Medical, Teleflex, Terumo. Dr Avran: Proctor for Boston Scientific, Abbott, Vascular Therapy, Biotronik, Asahi. Dr Khatri: Speaker’s bureau for Abbott, Boston Scientific, Shockwave, Medtronic, Terumo. Dr Alaswad: Consulting/speaker honoraria from Boston Scientific, Teleflex, CSI, LivaNova; provisional patent for TruVue intravascular ultrasound (IVUS)-guided reentry devices. Dr Jaffer: Canon, Siemens, Shockwave, Teleflex, Boston Scientific, HeartFlow, Neovasc, Orbus Neich; consultant/speaker fees from Medtronic, Magenta Medical, Shockwave, Novartis, Cleerly; equity interest in Intravascular Imaging, Inc, DurVena, Fastwave; intellectual property held by MGH; licensing arrangements with Terumo, Canon, Spectrawave, for which Dr Jaffer has the right to receive royalties. Dr Rinfret: Consulting, speaker, and proctoring honoraria from Abiomed, Boston Scientific, Medtronic, and Teleflex. The other author reports no conflicts.

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