Chronic Total Occlusions

12/2/2018 The PCR-EAPCI Textbook - Chronic total occlusions
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PART III CHAPTER 13
CHRONIC TOTAL OCCLUSIONS

Gerald S. Werner
SUMMARY
Chronically occluded coronary lesions make up about 20% of all coronary lesions, and the presence of a
chronic total coronary occlusion (CTO) in uences the decision on the therapeutic strategy. There are
numerous studies including a recent randomized trial to support the rationale of reopening a CTO (chronic
total occlusion) if viability and ischaemia are demonstrated in the territory distal to the CTO (chronic total
occlusion). The reluctance of many operators to attempt a CTO (chronic total occlusion) as a target lesion is
rather based on the complexity of the procedure, and the limited success rate than on any evidence that a
CTO (chronic total occlusion) is a benign lesion. However, recent developments in the technical approach,
both in strategy as well as available tools, have led to a greatly improved success rate for the recanalization
of a CTO (chronic total occlusion) which is now beyond 90% in experienced hands. Furthermore, persistent
patency and low lesion recurrence can now be achieved through the use of drug-eluting stents (DES). To
attain these improvements in technical success, operators need to undertake specialised training, and must
become familiar with the speci c tools and techniques of CTO (chronic total occlusion) intervention.
DEFINITION AND CLASSIFICATION

A chronic total occlusion (CTO) describes a completely occluded coronary artery. A variety of de nitions
existed regarding the TIMI (thrombolysis in myocardial infarction) (Thrombolysis in Myocardial Infarction)
ow and the duration of the occlusion. This in uences the comparison of data on acute and long-term
outcomes, and the advice given regarding which technical approach to undertake for crossing a lesion
successfully [1, 2].  
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In order to nd common ground for future discussions of technique and patient outcome, a consensus was
reached by a group of European experts suggesting a rm de nition of CTOs as those occluded arteries with
an angiographic documented or clinically suspected duration of occlusion of at least 3 months with
absolutely no ow through the lesion (TIMI 0 ow) [3]. Bridging collaterals may make it di cult to
discriminate between a total and a subtotal occlusion, therefore careful angiographic analysis in multiple
planes is required. Occlusions of 1 to 3 months duration can be addressed as recent occlusions, and within 4
weeks after an acute myocardial infarction, as subacute occlusions.
The basic pathological feature of a CTO (chronic total occlusion) consists rstly of a proximal cap, which is
often brotic or calci ed and may provide considerable resistance to wire advancement. Then along the
occlusion length there follows a segment of loose brous tissue or organised thrombus with various degrees
of adventitial and intraluminal neovascularisation, and variable extent of calci cation [4, 5]. The presence of
so called microchannels which might facilitate wire passage during intervention was based on these older
pathological studies, which included a number of subtotal CTOs not ful lling the modern day de nition. A
recent pathological study in a large group of CTOs, however, observed traversing microchannels infrequently
[137]. Sometimes, neovascularisation may establish antegrade ow through the lesion, and change the CTO
(chronic total occlusion) to a functional occlusion. If this segment is very long, as most often occurs within the
right coronary artery (RCA), multislice computed tomography (MSCT) might be helpful in de ning the general
direction of the vessel course and the extent of calci cation, and also in de ning whether such calci cation is
limited to the vessel wall or represents a calci ed central plaque occlusion. Finally, the distal cap needs to be
passed towards the segment distal to the occlusion which is often tapered and constricted and provides a
small target for the distal wire entry (  Figure 1 (104_1356_ gure1.png) ).
RATIONALE FOR INDICATIONS
THE PREVALENCE OF CHRONIC TOTAL OCCLUSIONS IN CORONARY ARTERY

DISEASE
The data on the prevalence of CTOs in patients with coronary artery disease varied from 20% to 30% [6, 8],
but contemporary large registries of consecutive patients from Canada [7] and Sweden [153] point to a
prevalence of 15-18%. Still, in contemporary clinical practice the number of CTOs makes up only 6% to 10%
of PCI (percutaneous coronary intervention) volume [9, 10, 11] [153]. In a nation wide survey of the US even
only 3.8% of PCI (percutaneous coronary intervention) procedures were conducted in CTOs [154]. CTO
(chronic total occlusion) represent a unique set of lesions not only because of the complexity of the required
interventional technique, but also with regards to the discordant view on the clinical indication to treat these
lesions. Historically the presence of a CTO (chronic total occlusion) meant medical therapy or referral for
CABG (coronary artery bypass grafting). In general, patients with a CTO (chronic total occlusion) present with
stable angina pectoris except if other coronary lesions progress and lead to unstable angina. Concurrent
CTOs pose a high risk if the collateral supplying artery is involved in an acute myocardial infarction, as the
territory at risk is increased [12, 13] (  Figure 2 (104_1357_ gure2.png) ).
 FOCUS BOX 1
CTO: De nition and prevalence
Duration of occlusion >3 months
No ow through the occlusion (TIMI 0)
20% of all coronary lesions detected at diagnostic angiography are CTOs
 FOCUS BOX 2
Anatomy of a CTO 

Fibrous proximal cap

Various degrees of calci cation
Loose tissue in the occlusion body (potentially organised thrombus)
Neovascularization (adventitial and luminal)
Distal cap
RATIONALE FOR TREATMENT

There are four main reasons to indicate whether a recanalization attempt should be made in a patient with a
CTO:
1. To relieve the exercise limiting symptoms of angina or dyspnoea, and, in moderately symptomatic
patients, to resolve ischaemia as detected by non-invasive stress testing;
2. To improve regional left ventricular (LV) function in the territory of the occluded artery, provided there
is residual viability as assessed by magnetic resonance imaging with late contrast enhancement;
3. To improve the prognosis of the patient as there is considerable risk of future progression of coronary
artery disease in the remaining patent arteries.
4. To achieve complete revascularisation in multi-vessel disease.
Improvement of symptoms
In a meta-analysis of trials comparing successful and unsuccessful procedures the impact on clinical
symptoms of angina was analysed [14]. In six trials in which recurrence of angina was reported, this event
occurred about 50% more often after an unsuccessful as compared to a successful procedure [15, 16, 17, 18,
19, 20] (  Figure 3 (104_1358_ gure3.png) ). This meta-analysis compared 1,030 successful with 570
unsuccessful procedures, the success rate in these studies was well below 70% as the studies originated
from a period before advanced recanalization techniques had been introduced. Lesion recurrence, leading
to a recurrence of symptoms, was a frequent observation in the era of balloon angioplasty and bare metal
stent (BMS) treatment of CTOs [21, 22, 23].
The problem with symptoms related to a CTO (chronic total occlusion) is their often atypical presentation.
Unlike patients with non-occluded lesions, there is a baseline collateral blood supply to the myocardial
territory distal to the occlusion which is fully developed after about 3 months of occlusion duration [24]. The
chronic nature of the situation may lead patients to adapt to their limited exercise capacity and not report
this limitation as an acute symptom. More often the patient will experience dyspnoea at higher exercise
levels rather than typical angina.
The e ect of a successful revascularisation was recently evaluated by the Seattle Angina Questionnaire (SAQ)
to assess quality of life (QoL) in the FACTOR trial [25]. The authors observed an improvement in QoL (quality
of life) after successful PCI (percutaneous coronary intervention), which was most pronounced in patients
with a symptomatic state before PCI (percutaneous coronary intervention), whereas the improvement was
less evident in asymptomatic patients. In a comparison of clinical symptoms at baseline and after successful
treatment between patients with and without a CTO (chronic total occlusion) as target lesion, the physical
limitation assessed by the SAQ (Seattle angina questionnaire) was more severe, but the improvement after
treatment more pronounced in CTO (chronic total occlusion) patients [138].
Many of the patients with a CTO (chronic total occlusion) will be considered patients with silent ischaemia.
Despite the observation that collaterals will prevent regional dysfunction and MI in many of these patients,
the functional capacity of the collateral system to increase myocardial blood supply during exercise is limited
[26, 27]. The fractional ow reserve (FFR) assessed distal to an occluded artery is typically in the range below
0.5 [28], which clearly indicates myocardial ischaemia [29, 30]. As there is a considerable amount of data
supporting the revascularisation of coronary lesions causing silent ischaemia of more than 10% of

myocardial volume [31, 32, 33], as re ected in the recent ESC-EACTS guidelines on myocardial
revascularisation [34], this applies also to CTOs with a similar evidence of myocardial ischaemia. Based on
the aforementioned subjective adaptation to clinical symptoms, the performance of quantitative ischaemia
tests should be encouraged in asymptomatic patients with CTOs.
Improvement of LV (left ventricle) function

The potential e ect of a reopened CTO (chronic total occlusion) on LV (left ventricle) function was established
with the rst attempts to treat CTOs by PCI (percutaneous coronary intervention), but no randomised trial
has been performed, and the only data are derived from comparing failed and successful PCI (percutaneous
coronary intervention) attempts. When reviewing these early studies one needs to bear in mind that they
were done with balloon angioplasty alone, or with BMS (bare metal stent) later on, but not with DES (drug-
eluting stent). Lesion recurrence as a major detrimental factor for the functional improvement was very high
in those studies [35]. The e ect of global LV (left ventricle) function as assessed by ejection fraction (EF) is
generally less pronounced than the e ect on regional function. The improvement of LV (left ventricle) EF
(ejection fraction) varied, but vessel patency was mandatory for the achievement of LV (left ventricle)
recovery [36, 37, 38, 39, 40, 41]. Other predictors of LV (left ventricle) improvement were a shorter duration
of occlusion (<6 months), and a more severely impaired LV (left ventricle) function at baseline (<60%) [42].
In the case of ischaemia related regional impairment as assessed by dobutamine stress echocardiography,
functional recovery may take place immediately after a successful PCI (percutaneous coronary intervention)
[43]. LV (left ventricle) recovery starts within 1 to 4 weeks after revascularisation and is usually complete
within 3 months [44, 45, 46]. Although these studies were done after surgical revascularisation, they are
probably applicable also to PCI (percutaneous coronary intervention). Most studies cited above evaluated LV
(left ventricle) recovery after PCI (percutaneous coronary intervention) at a follow-up of 6 to 12 months, but
may take longer in some cases [47].
Recovery of LV (left ventricle) function in chronically ischaemic myocardium depends on the presence of
hibernating or stunned but viable myocardium [48, 49]. Magnetic resonance imaging (MRI) is now the gold
standard to detect irreversibly damaged myocardial scar tissue, and helps to highlight where
revascularisation (surgical and interventional) is indicated. When MRI (magnetic resonance imaging) is
applied to patients with a CTO (chronic total occlusion), the transmural extent of late enhancement and also
the residual wall thickness of viable myocardium are related to the improvement of LV (left ventricle)
function after PCI (percutaneous coronary intervention) [50, 51]. The extent of transmural late enhancement
is a readily available measure, however, a linear relationship with LV (left ventricle) recovery is di cult to
establish as, among other factors, the spatial extent needs to be considered as well. So at present, de nite
LV (left ventricle) function improvement is predicted with a cut-o value of late enhancement of <25% wall
thickness, with a large grey zone with uncertainty of recovery of 25% to 75% wall thickness. Some further
improvement can be expected in this "grey" zone between 6 months and 3 years after PCI (percutaneous
coronary intervention), but these improvements are moderate [52]. The additional use of low-dose
dobutamine stress during the MRI (magnetic resonance imaging) examination protocol may improve the
prediction of wall motion recovery and improve the indication for revascularisation [139]. No recovery is
expected with complete transmural extent of scar tissue (  Figure 5 (104_1359_ gure4.png) ).
Improvement of prognosis
In patients with stable angina pectoris, no single large randomised clinical trial on revascularisation versus
medical therapy has so far shown an improvement in survival. Still the debate is open as to whether
individual trials had enough power to detect a prognostic di erence [53]. One of many meta-analysis
concluded that there is indication of a survival bene t when treating patients with stable angina by PCI
(percutaneous coronary intervention) [54], but this opinion is not uniformly supported and needs further  
corroboration from a future larger scale randomised trial [55]. Recent epidemiologic data from Sweden’s
SCAAR (Swedish Coronary Angiography and Angioplasty Registry) registry support the fact that the presence
of a CTO (chronic total occlusion) is associated with increased cardiac mortality[156].
If we look at a very large registry of CTO (chronic total occlusion) PCI (percutaneous coronary intervention)
from UK including more than 13000 patients [157], a mortality bene t in patients with a successful PCI
(percutaneous coronary intervention) as compared to failed procedures was demonstrated, but the absolute
values after 3 years were just 5 vs 7% and the signi cance of the di erence was derived from the large
number of patients. If such a bene t would be addressed in a randomized trial, one should keep in mind that
randomized trials tend to include less symptomatic patients, and the likelihood of showing a di erence in
survival in a low risk selection of patients will be low. The one year mortality in the UK registry was between 2
and 3%, whereas in a recent randomized trial the one year mortality of enrolled patients in the PCI
(percutaneous coronary intervention) arm was just 0.8% [155], underscoring the selection bias in the
inclusion process of randomization.
Because CTOs have a low likelihood of interventional success they are not well represented in trials on stable
angina. That the risk of leaving a CTO (chronic total occlusion) alone is not negligible is highlighted by the
observation of the severe prognostic impact on outcome if an acute MI occurs in the presence of a CTO
(chronic total occlusion) in one of the other arteries. The 30 day mortality is tripled despite the STEMI (ST-
elevation myocardial infarction) treatment by primary PCI (percutaneous coronary intervention) [12], and the
incidence of cardiogenic shock increases [13]. The further long-term prognosis of the initial survivors is
adversely in uenced through a follow-up of 5 years [56] (  Figure 6 (104_1360_ gure5.png) ). The negative
prognostic impact in patients experiencing a STEMI (ST-elevation myocardial infarction) was also con rmed
by post-hoc analysis from randomized trials of STEMI (ST-elevation myocardial infarction) PCI (percutaneous
coronary intervention) such as the HORIZONS and TAPAS trials[158, 159]. The randomized EXPLORE trial was
designed to assess the potential impact of a CTO (chronic total occlusion) PCI (percutaneous coronary
intervention) within 7 days after a STEMI (ST-elevation myocardial infarction) as compared to OMT (optimal
medical therapy) looking at changes of LV (left ventricle) function as a primary endpoint, and clinical
secondary endpoints. In 304 randomized patients, however, no positive in uence of CTO (chronic total
occlusion) PCI (percutaneous coronary intervention) was observed after 4 months, and no clinical
di erence[160]. The problem of this trial was the long inclusion period of 8 years for a low number of
patients, a low success rate of 73%, and the selection bias that will have excluded the most impaired
patients.
A number of registries reported on the long-term outcome of patients undergoing PCI (percutaneous
coronary intervention) for CTOs. However, all these data are comparisons between failed and successful
procedures, and not randomised. Despite this crucial shortcoming, the uniform impression is that successful
recanalization has a positive e ect on survival (  Figure 7 (104_1361_ gure6.png) ). However, one should
be cautious in extrapolating these registry observations as there are limitations in selection bias, and above
all they represent data mainly from a historical perspective that is no longer comparable to today’s standard
of treatment [15, 16, 17, 18, 19, 20, 57, 58, 59, 60, 61, 62, 63]. One uniform observation in many of these
studies was the reduced need for CABG (coronary artery bypass grafting) among patients with successful PCI
(percutaneous coronary intervention) for CTOs (  Figure 8 (104_1362_ gure7.png) ).
A recent large registry from Japan extended to the era of DES (drug-eluting stent) and modern recanalization
techniques [64]. They compared patients with persistent patent arteries at follow-up with those with initial or
late failure of patency, and observed a signi cant di erence in the survival rate of 92% versus 64% after 6
years. This registry stands out from the other data as it takes early failure and late reocclusion together and
basically presents the comparison of long-term patent and re/occluded CTOs. Persistent patency might be an
important additional factor for prognostic bene t, which is clearly better nowadays with DES (drug-eluting

stent) than it had been in the era of balloon angioplasty and BMS (bare metal stent). Several registries and
one randomised trial have con rmed nally, that CTOs should receive DES (drug-eluting stent) due to the
higher recurrence rate after BMS (bare metal stent) [23].
Complete revascularisation in multivessel disease

The important negative impact of incomplete revascularisation on prognosis was reemphasised by the
analysis of the SYNTAX (SYNergy between percutaneous coronary intervention with TAXus ) trial. A high
residual SYNTAX (SYNergy between percutaneous coronary intervention with TAXus ) score (rSs) is related to
increased mortality. The SYNTAX (SYNergy between percutaneous coronary intervention with TAXus ) score is
heavily in uenced by the presence of a CTO (chronic total occlusion), and therefore the presence of a CTO
(chronic total occlusion) was the best predictor of incomplete revascularisation. CTOs are found in half of the
patients with the highest rSs, which is explained by the low revascularisation success for CTOs within the
SYNTAX (SYNergy between percutaneous coronary intervention with TAXus ) trial PCI (percutaneous coronary
intervention) arm of less than 50% [140, 141]. The relevance of CTOs as a major determinant of incomplete
revascularisation is further supported by the application of the rSs on other studies like the ACUITY (acute
catheterization and urgent intervention triage strategy) trial in a post-hoc analysis [142]. In the recent
SYNTAX (SYNergy between percutaneous coronary intervention with TAXus ) II study modern function and
imaging-based PCI (percutaneous coronary intervention) technique were applied and a considerably higher
success rate in CTOs of 87% as compared to the 50% success rate in the original SYNTAX (SYNergy between
percutaneous coronary intervention with TAXus ) PCI (percutaneous coronary intervention) arm was
achieved, leading to a considerably better outcome when compared to the historic PCI (percutaneous
coronary intervention) and CABG (coronary artery bypass grafting) arm of the SYNTAX (SYNergy between
percutaneous coronary intervention with TAXus ) study[161]. This underscores the relevance of treating
multivessel patients with adequate PCI (percutaneous coronary intervention) technique including the
revascularization of any CTO (chronic total occlusion) in these patients in order to achieve an outcome
comparable to CABG (coronary artery bypass grafting).
Evidence from randomized trials

In 2017 two randomized trials of CTO (chronic total occlusion) PCI (percutaneous coronary intervention)
versus optimal medical therapy (OMT) had been presented in patients with stable angina, but only one of
them is fully published. The DECISION-CTO study was presented at the American College of Cardiology
Annual conference 2017. This trial in 834 patients with stable angina inclusing a CTO (chronic total occlusion)
as one of their lesions, showed no di erence between PCI (percutaneous coronary intervention) and OMT
(optimal medical therapy) regaring the primary endpoint of death, MI, stroke or revascularization. In
addition, both groups showed a similar improvement of SAQ (Seattle angina questionnaire) subscales after
randomiation and treatment. However, the trial design was compromised by the fact, that non-CTO lesions
were treated after the baseline assessment. As 77% of patients having multi-vessel disease in DECISION-CTO,
this meant, that about 70% of patients in the OMT (optimal medical therapy) arm of DECISION-CTO received
PCI (percutaneous coronary intervention), which explains an improved SAQ (Seattle angina questionnaire)
even in the OMT (optimal medical therapy) group. The trial took more than six years to enrol, but presented
a very high success rate of 90% for the CTO (chronic total occlusion) lesion. The other trial is the EUROCTO
trial, presented at EuroPCR 2017, and now available in print [155] has a similar patient population, but the
main di erence was, that all of the 448 enroled patients were treat for the hemodynamically relevant
non_CTO lesion before randomization and baseline assessment. Therefore, all confounding e ects of the
non-CTO treatment were eliminated. This trial showed with a high procedural success rate and a low cross-
over rate from OMT (optimal medical therapy) of 7% in the intention-to-treat analysis, that the SAQ (Seattle
angina questionnaire) subscales of angina frequency and quality of life were signi cantly reduced in the PCI
(percutaneous coronary intervention) group as compared to the OMT (optimal medical therapy) group. This 
manifested that a positive endpoint was reached with a statistical power of 81%. In addition physical
limitation was considerably reduced, as well as the CCS (Canadian Cardiovascular Society) class at follow-up
at no signi cant extra risk during the clinical follow-up ( Figure 4 (104_3487_FigureX1.jpg)). Both studies
are in fact not contradictory, as the EUROCTO trial assessed the isolated bene t of CTO (chronic total
occlusion) PCI (percutaneous coronary intervention), whereas DECISION-CTO tested the additional bene t of
CTO (chronic total occlusion) PCI (percutaneous coronary intervention) in addition to non-CTO PCI
(percutaneous coronary intervention). The latter could not address in proper numbers the isolated e ect of
CTO (chronic total occlusion) PCI (percutaneous coronary intervention), but showed that at least the
combined non-CTO and CTO (chronic total occlusion) PCI (percutaneous coronary intervention) did not lead
to increased events during a three year follow-up.
 FOCUS BOX 3
Indications for revascularisation of a CTO
Clinical symptoms of angina and/or dyspnoea related to a CTO
Impaired LV (left ventricle) function with documented viability supplied by a CTO
Large myocardial territory (>10%) supplied by a CTO
Complete revascularization in patients with multivessel disease
A prerequisite for revascularisation of a CTO (chronic total occlusion) is the presence of
collaterals
A randomized trial showed that PCI (percutaneous coronary intervention) for smyptomatic
CTOs imporves Quality of life.
THE FUNCTIONAL CAPACITY OF COLLATERALS

Collaterals are inter-arterial connections that provide blood ow to a vascular territory whose original supply
vessel is obstructed. Thus, the integrity of the organ supplied by the obstructed vessel may be preserved or
to a certain degree impaired but would not become necrotic. In the coronary vascular system such
connections are familiar to every investigator who performs angiographic imaging of patients with coronary
artery disease. They develop through arteriogenesis, that is, through the recruitment of preformed and pre-
existing inter-arterial connections mainly driven by shear forces along the pressure gradient that develops
when the native vessel is occluded [65]. Some of these connections may be preformed to such an extent that
they are immediately recruitable during vessel occlusion, as shown during balloon occlusion in non-diseased
coronary arteries [66]. The functional assessment of collaterals, as mentioned below, has revealed that in
patients without well-developed pre-existing collateral connections, collaterals required between 2 to 12
weeks to fully develop their functional capacity [67].
The size of the inter-arterial connections varies over a wide range from between 40 and 200 μm. However,
the size of the majority of these vessels is below the spatial resolution even of analogue angiographic
imaging. With today’s digital storage media and a resolution of >0.2mm, quantitative coronary angiography
of collaterals, which would be ideal, is limited. The most widely used angiographic grading system described
by Rentrop et al does not actually rate the collaterals themselves, but their e ect in lling the occluded
arterial segment [68]. It distinguishes four degrees of collateral recipient artery lling by radiographic
contrast medium: grade 0=no collaterals; grade 1=side branch lling of the recipient artery without lling of
the main epicardial artery; grade 2=partial lling of the main epicardial recipient artery; grade 3=complete
lling of the main epicardial recipient artery. Further re nements of qualitative angiographic methods
consider other aspects of coronary collateral angiographic appearance, such as collateral ow grade, frame
count, bifurcation count, collateral length grade, the relationship between the area at risk for myocardial
infarction and collaterals, and collateral recipient vessel lling.


The Rentrop classi cation of angiographic collateral assessment was developed in the context of acute
myocardial infarction and the time frame of rst appearance of collaterals after an acute occlusion. However,
in CTOs, the majority of collaterals provide Rentrop 3 lling. A di erent angiographic description of
collaterals, which is also related to physiological function, is based on the visual estimation of the collateral
diameter, the collateral connection grade according to Werner et al [67]. This has gained relevance for the
assessment of collateral pathways as possible interventional routes in the so-called retrograde approach
(see below).
The physiological assessment of collateral function is best done with combined pressure and ow velocity
recordings with microsensors [68]. This provides a complete picture of the haemodynamics of the
collateralised territory distal to an obstruction with the serial arrangements of 3 major conductance
pathways relevant for collateral perfusion, that is (1) the conductance through the collateral proper, which is
determined by the length and diameter of these collaterals, which may often show a tortuous vessel course,
(2) the conductance in the segment of the collateral donor artery, where di use atherosclerosis may impede
ow to the collaterals, and (3) the conductance of the arteriolar rami cations of the microcirculation of the
myocardium distal to the occlusion [26, 27].
The phenomenon when collateral supply regresses during exercise is described as coronary steal. One of the
major factors involved in coronary steal is the presence of a signi cant lesion in the collateral donor artery
[27]. The fact that a larger myocardial area is subtended by a donor artery segment when it feeds the main
collateral supply may lead to a low FFR (fractional ow reserve) value of the donor artery lesion. Once the
CTO (chronic total occlusion) is revascularized, the same lesion might show a higher FFR (fractional ow
reserve) value as the myocardial mass distal to the lesion is then reduced. Therefore, physiologically driven
revascularization in a donor segment needs to take this observation into account speci cally when the
values are near the cut-o value[162, 163].
Collateral function can develop to a similar functional level in patients post myocardial infarction with large
akinetic territories as in patients with normal preserved regional function. The presence of viability is not a
prerequisite for collateral development. This is in accordance with experimental studies on arteriogenesis,
namely that the pressure drop along preformed inter-arterial connections is the driving force to recruit these
connections in the presence of occlusion of the native artery [70] (  Figure 5 (104_1359_ gure4.png) ).
It is known that collaterals have the capacity to prevent myocardial necrosis and may even uphold metabolic
supply to the territory distal to an occlusion to maintain full contractile capacity. But direct assessment of
collateral function shows that the functional competence of collaterals in CTOs is limited even in patients
without a prior Q-wave MI. During a standard stress protocol with systemic infusion of adenosine the
coronary ow velocity and pressure changes distal to an occlusion were well below cut-o values for
assessing the functional reserve in non-occlusive coronary obstructions, that is a ow velocity reserve above
2, and an FFR (fractional ow reserve) above 0.75. So even well-developed collaterals would not prevent
ischaemia during exercise [26, 27] (  Figure 9 (104_1363_ gure8.png) ).
Collaterals will regress once the native artery that was supplied by the collaterals is revascularized. This
process starts immediately after the re-established antegrade ow with immediate loss of collateral
conductance and extends further many months after the angioplasty or revascularisation procedure. Acute
reocclusion for example in the course of a late stent thrombosis would therefore lead to an acute coronary
syndrome in most cases [71, 72], as the recruitment of collaterals is not instantaneous in most patients [73].
 FOCUS BOX 4
Role and signi cance of collateral channels
Collaterals develop within 3 months of an occlusion
Collaterals develop from preformed arteriolar connections 

Collaterals may prevent MI when an occlusion develops gradually

The FFR (fractional ow reserve) of a coronary artery lesion that supplies collaterals may
increase after revascularization of the CTO
The majority of collaterals do not have the capacity to prevent myocardial ischaemia during
exercise
INDICATION FOR CTO (CHRONIC TOTAL OCCLUSION) PCI (PERCUTANEOUS

CORONARY INTERVENTION) BASED ON CURRENT (CLOPIDOGREL OPTIMAL
LOADING DOSE USAGE TO REDUCE RECURRENT EVE) GUIDELINES
The ESC-EACTS guidelines on myocardial revascularisation clearly state that a CTO (chronic total occlusion),
like any other coronary lesion, requires revascularisation if it causes symptoms or ischaemia [34]. There is a
considerable amount of data supporting the revascularisation of coronary lesions causing silent ischaemia of
more than 10% of myocardial volume [31, 32, 33], this applies also to CTOs with a similar evidence of
myocardial ischaemia. Based on the aforementioned chronicity of and adaptation of clinical symptoms, the
performance of quantitative ischaemia tests should be encouraged in asymptomatic patients with CTOs.
Which mode of revascularisation - surgery or PCI (percutaneous coronary intervention), is not clearly de ned
and should depend also on factors such as the presence of multivessel disease, involvement of the left main
coronary artery, impairment of LV (left ventricle) function as well as the general prognosis and comorbidity of
a patient.
The fact that CTOs are speci cally addressed as a subset of coronary lesion with additional rating is
historically based on the fact of previously very low success rates of CTO (chronic total occlusion) PCI
(percutaneous coronary intervention). There is no clinical evidence that would justify to consider a CTO
(chronic total occlusion) a less severe lesion than a high-grade stenosis. The success rate of a proposed PCI
(percutaneous coronary intervention) for a CTO (chronic total occlusion) must therefore be taken into
consideration as compared to alternative modes. A recent decision algorithm for indicating CTO (chronic
total occlusion) PCI (percutaneous coronary intervention) is based on the presence of symptoms and
viability, which is basically the same reasoning that governs PCI (percutaneous coronary intervention)
indication in general [164] ( Figure 10 (104_3488_FigureX2.jpg)).
HOW TO APPROACH A CTO
LOGISTICS
That a CTO (chronic total occlusion) requires speci c techniques was recognised early by the pioneers of CTO
(chronic total occlusion) recanalization such as Geo rey Hartzler [74] and Bernhard Meier [75]. The
procedural success rate of PCI (percutaneous coronary intervention) in CTOs was initially in the range of 50%,
that is why early guidelines for PCI (percutaneous coronary intervention) even stated that the presence of a
CTO (chronic total occlusion) was a contraindication for PCI (percutaneous coronary intervention) [1, 74].
However, this has changed considerably over the past two decades due to the technical developments
described below [76, 77] (  Figure 11 (104_1364_ gure9.png) ). The success rates in the hands of dedicated
expert operators can reach a level of more than 90%, and the ESC-EACTS guidelines on myocardial
revascularisation suggest a minimum level of 80% success rate for those who perform PCI (percutaneous
coronary intervention) in CTOs [34].
There are several general considerations for the planning of a CTO (chronic total occlusion) procedure. A
staged approach is often a reasonable strategy in multivessel disease in order to avoid excessively long
procedures. Consideration of which artery to tackle rst, the CTO (chronic total occlusion) or the non-
occluded vessel(s), should be based on the importance of the occluded vessel (if the vessel and the amount
 
of viable myocardium is important, the CTO (chronic total occlusion) should be approached rst, while with
poor contralateral ow or an intended retrograde approach the stenosis in the contralateral vessel may
need to be treated rst). Additionally, inverted collateral ow through the recanalized CTO (chronic total
occlusion) may protect myocardium at risk during treatment of high risk complex lesions in the collateral
donor vessel. It is important that each case is considered individually and carefully, and the consequences of
success or failure of the individual lesion treatments be taken into account.
In acute coronary syndromes, the use of a staged procedure with immediate initial treatment limited to the
culprit artery is often easier and clinically sound. There is no doubt that in ST-elevation myocardial infarction,
treatment should be limited to the culprit infarct-related vessel and all other lesions, especially CTOs, should
be referred for subsequent evaluation and possible treatment depending on evidence of ischaemia and
viability[165]. Furthermore, patients who receive glycoprotein IIb-IIIa inhibitors during a procedure for an
acute syndrome should not undergo CTO (chronic total occlusion) revascularisation with this non-reversible
potent antithrombotic agent on board.
OPERATOR EXPERIENCE AND TRAINING ( CHAPTER 4.10

(/EUROINTERVENTION/TEXTBOOK/PCR-TEXTBOOK/CHAPTER/?CHAPTER_ID=154) )
If we assume that less than 10% to 15% of the total PCIs attempted are CTOs and we recommend a
minimum number of 50 CTO (chronic total occlusion) cases per year to maintain competency, a large volume
laboratory with more than 1,000 interventions per year can provide continuous training to no more than 2 to
3 operators. The current trend to allow low volume centres to start an interventional programme to reduce
in-hospital waiting time and to allow patients to have local access to acute procedures such as primary
angioplasty, often creates centres with a workload and patient mix such that no operator can perform a
su cient number of CTO (chronic total occlusion) procedures to maintain acceptable competency.
Transferring the patient to a larger centre or developing a programme of proctorship with guest operators
coming to help for the most complex cases are possible solutions. Absence of surgical back-up is not, per se,
a contraindication to develop a CTO (chronic total occlusion) treatment programme but the appropriateness
of indications must be con rmed by the regular involvement of cardiac surgeons as and when required, and
the centre must con rm it has the ability to deal promptly with complications such as cardiac tamponade, as
well as the safe and rapid transfer of the few cases who potentially require emergency cardiac surgery.
The availability of high quality digital at panel detectors, a su cient variety of guiding catheters and wires,
including dedicated wires, and the possibility to use multiple balloons and drug-eluting stents to cover the
entire occluded segment are required for centres willing to maintain an active CTO (chronic total occlusion)
programme. Biplane imaging, availability of IVUS (intravascular ultrasound) and of the Rotablator® (Boston
Scienti c, Natick, MA, USA) are desirable additions for CTO (chronic total occlusion) recanalization, but
cannot be considered indispensable.
In Europe, speci c training in interventional cardiology is not required and most new specialists commence
interventional cardiology upon completion of their training with limited theoretical knowledge and often only
modest practical experience. It is important that all angiographers understand that occlusions require
acquisitions in multiple views, that the acquisition must be prolonged to visualise the distal segments lled
by collaterals and that the source of collaterals must be optimally and selectively engaged (for example the
conus branch for LAD (left anterior descending) occlusions, the LIMA (left internal mammary artery) for RCA
(right coronary artery) occlusions) [78].
The European Association of Percutaneous Cardiovascular Interventions (EAPCI) published, in 2005, a

Curriculum and Syllabus to establish an optimal homogeneous pattern of training in Europe [79]. After a 2
year training period the candidate is expected to tackle complex angioplasty as primary operator and CTOs
are mentioned as part of the experience required. We believe that all centres involved in the training of
 
interventional cardiologists should be engaged in a regular programme of CTO (chronic total occlusion)
recanalization. The growth in frequency and success rates in treating CTOs in Europe is critically dependent
on a robust initial process of training o ered to all interventional fellows. The training experience should be
su cient to overcome the steepest initial phase of the learning curve, allowing the trainee to comfortably
approach at least the simplest CTOs with the appropriate equipment and strategy to achieve success, and to
have gained su cient knowledge and experience to stop before complications occur or, in the worst
scenario, to treat e ciently the most common speci c problems.
It is proposed that 30 CTO (chronic total occlusion) procedures (primary/secondary operator) are part of the
200 angioplasty package required to complete the training successfully [79]. The role of the trainee can be
variable, based on the complexity of the CTO (chronic total occlusion) procedures performed, and the level of
training reached. It makes no sense that a trainee with less than 6 months experience in angioplasty and
who may still be experiencing problems in crossing simple subtotal stenosis should face the subtleties of
wire handling in di cult CTOs, but they can certainly bene t from a role as secondary operators in these
complex CTO (chronic total occlusion) cases. For each trainee a complete logbook should indicate in detail
the CTO (chronic total occlusion) anatomies and techniques the candidate has been exposed to, and the
supervisor should give a speci c evaluation of the level of training reached in CTO (chronic total occlusion)
recanalization.
CHOOSING THE MOST APPROPRIATE STRATEGY FOR A CTO

The advances of interventional therapy for CTOs over the past decade, and even since the rst print edition
of this chapter, are remarkable. The challenge for the experienced operator is now to choose the most
appropriate strategy for each type of lesion. The ultimate goal should be to treat the patient successfully in
one treatment session, and, thus, choose that approach with the highest likelihood of success, and switch to
alternative strategies in case of failure of “plan A“, and ideally have further options available. It is
recommended not to linger too long with a failing technique and be ready to switch options quickly.
However, there maybe anatomic situations where only one approach is likely to succeed, such as a
retrograde option, and then the necessary time needs to be invested to achieve the collateral passage. To
apply such a versatility in the approach to CTO (chronic total occlusion) PCI (percutaneous coronary
intervention), the expertise and knowledge is required of all basic and advanced techniques discussed in the
subsequent parts of this chapter.
The choice of the primary and secondary strategy, and additional alternatives depends on the operator’s skill
and familiarity with di erent approaches and devices (  Figure 42 (104_2687_ gure39_update.jpg)). In the
US the so called “hybrid approach” has been advertised as one that incorporates a liberal use of dissection-
and-re-entry by the StingRay catheter in about one third of cases [151, 152]. In countries with less
commercial penetration of this device the retrograde approach is favoured as an early alternative route in
case of antegrade wire failure. Also the use of IVUS (intravascular ultrasound) as a tool to help redirect a wire
from the subintimal path or even avoid such a route by identifying the proximal entry point will not be
familiar to every operator.
A synthesis of both the dissection-reentry option and the more wire-based approach developed in Japan with
a speci c focus on the possibility of parallel wiring with new more controllable guide wires is incorporated in
the so called “Asian Paci c algorithm”[166]. These algorithms in general aim to provide decision trees based
on anatomic features of the CTO (chronic total occlusion) combined with the availability of collateral
pathways as potential interventional routes. In order to determine the optimal strategy, the major perquisite
is the optimal visualization of the occluded vessel anatomy as well as the collateral donor vessel.
 FOCUS BOX 5
Expertise requirements for CTO (chronic total occlusion) intervention


PCI of CTOs should be performed by specially trained operators

PCI of CTOs is an elective procedure and should not be done ad hoc
Careful planning of the procedure and allotment of su cient lab time are required
A continuous workload of 50 cases per year is advisable to acquire and maintain expertise
At the start of the procedure, the principal and alternative strategies need to be determined
Algorithms can help to choose the appropriate strategic approach to CTO (chronic total
occlusion) PCI
BASIC TECHNIQUES
The complication rate, inherent to a regular PCI (percutaneous coronary intervention), is not smaller when a
CTO (chronic total occlusion) is attempted[167]. Although the artery is already occluded at the beginning of
the procedure, considerable damage could be in icted on the supplying collaterals during the procedure,
with ensuing infarction. similar to an acute occlusion during a procedure in a non-occluded artery.
A CTO (chronic total occlusion) is a lesion where the distal segment is not clearly visible, and the actual
course of the vessel is completely obstructed and cannot be readily assessed from angiography especially in
long occlusions. To cross a CTO (chronic total occlusion) we need to visualise the distal segment in order to
check the position of the guidewire, and we often need to resort to more rigid wires than in non-occlusive
lesions. The latter are associated with a potential to damage to the arterial wall, deviate into the subintimal
vascular space, or even perforate towards the pericardium, which requires special emphasis on control of
the wire progress during every step of wire manipulation.
The absolute prerequisite for a CTO (chronic total occlusion) procedure is to reduce risk and avoid
complications. The indication is a mere symptomatic one, as prognostic considerations are not backed by a
randomised study. Therefore, the CTO (chronic total occlusion) procedure must not harm the patient in any
way, and one must be absolutely sure where the tip of the wire is positioned.
ACCESS SITE
The basic requirement for a successful CTO (chronic total occlusion) procedure is to provide enough guide
catheter support for wire and device passage of a lesion. This can be achieved by using large guide catheters
of 8F, which require generally a femoral route if not sheeth-less guides are used transradially. However, the
development of radial access including the smaller outer diameter of so called slender sheaths makes it
possible to also use at least regular 7F catheters for both antegrade and contralateral access routes.
Therefore, a trend of the past years is to combine radial and femoral approach or even use a biradial
approach. By using aggressive catheter shapes and/or support techniques as described below, the
procedural success might be equivalent to the femoral route in experienced hands [143]. The radial
approach is in any way an alternative access in patients with severe peripheral artery disease. The main
concern will remain with ostial RCA (right coronary artery) lesions where the use of a special backup catheter
is denied and a larger 8F catheter combined with a long access sheath will provide the best possible backup.
ANGIOGRAPHIC VISUALISATION
The angiographic appearance of the occlusion may help decide the initial strategy. When faced with a ush
ostial occlusion of the RCA (right coronary artery), the left anterior descending (LAD) or left circum ex artery
(LCX), this is one of the undisputed situations where the retrograde approach via collaterals should be
considered as the primary strategy. In all other situations the CTO (chronic total occlusion) can be


approached by the antegrade approach as the primary strategy. Di erent angiographic shapes with a
tapered entry, a blunt occlusion or a side-branch without clear identi cation of the entry into the occlusion
cap need to be recognised (  Figure 12 (104_1365_ gure10.png) ).
In addition, to visualise the proximal anatomy of the CTO (chronic total occlusion), it is mandatory to visualise
the distal segment so as to obtain an idea of the course of the vessel within the invisible occluded segment.
The length of the occlusion is often misjudged, and a simultaneous coronary injection will elucidate the
situation (  Figure 13 (104_1366_ gure11.png) ). A second sheath for injection of contrast to visualise the
collateral lling from the contralateral artery is always mandatory except in those cases where we have
ipsilateral collaterals lling the distal lumen. However, antegrade wire progress may occlude this ipsilateral
collateral source, and then contralateral injection is needed for visualisation. Therefore, in the latter case, the
second access site should be prepared, and the second sheath inserted immediately should distal
visualization from ipsilateral collaterals be lost. For an antegrade recanalization approach it is often su cient
to use a small diagnostic sheath (4 Fr or 5 Fr) for the contralateral visualization. Larger diameters will
increase the contrast use during the procedure, but are sometimes required to visualize small collateral
connections which become visible only with adequate contrast injections..
Intracoronary injection through microcatheters is not advised, as if positioned in the subintimal space, this
will lead to contrast obstruction of the true lumen and dissection and make further progress futile. However,
there is no rule without exemptions, and in cases of poor visualisation via collaterals or within a long-
occluded segment and unexplained lack of progress, a gentle injection through the microcatheter may be
tried if blood can be aspirated indicating an intraluminal position. If no blood is aspirated, the injection is
most likely directed into the subintimal space, which is discouraged as it obliterates the true lumen even
more, and the procedure might need to be stopped. There are reports that an antegrade injection into the
occlusion through the microcatheter may facilitate the wire recanalization [80], but the reported success
rates with this approach are low as compared to current standards [77].
 FOCUS BOX 6
Procedural tips and tricks
Angiographic imaging of the distal coronary bed is mandatory during a CTO PCI
Bilateral catheter insertion is necessary in the majority of patients without ipsilateral
collaterals
Simultaneous dual injection helps to de ne the vessel course and the anatomy of the CTO
Intracoronary injection through microcatheters into the CTO should be avoided
GUIDE CATHETER SUPPORT ( CHAPTER 3.1

At the beginning of the procedure, we must ensure that there is su cient guide catheter back-up not only
for the wire passage, but also for subsequent balloon and stent advancement. Especially for the RCA (right
coronary artery), the regular right Judkins guide may not provide adequate support. However, there is a
balance to be made between catheter size and shape, and this requires careful planning right at the start of
the procedure. A large diameter, such as 8 Fr, will provide enforced support even with the less aggressive
regular Judkins right curve, and it provides ample working space for complex techniques of double wires,
anchoring balloon, intravascular ultrasound (IVUS) guidance etc. This approach is especially important for
proximal or ostial occlusions, where deep guide engagement is not possible or counterproductive. For
lesions close to the ostium of the RCA (right coronary artery), a proper alignment of the guiding catheter with
the vessel course is crucial (  Figure 14 (104_1367_ gure12.png) ), and this may not always be achieved
with a Judkins shape. An alternative in this instance could be an internal mammary guiding catheter. In non-
ostial lesions a smaller guide size of 6 Fr will require deeper engagement for adequate support. This can be 
ideally achieved with a left Amplatz 1 or 0.75 curve. It is important for the RCA (right coronary artery) to
always use catheters with side holes, to avoid local dissections during contrast injection into the occluded
proximal artery.
For the left coronary artery, the guide catheter has to be selected according to the length of the left main
artery, and the angle of take-o of the occluded artery. Given that CTOs considered worthwhile for
treatment will generally be located in the main arteries, recanalization of the left anterior artery (LAD) may
be well supported by an extra backup shape, while occasionally the classic Amplatz left 2 or 3 shapes may be
ideal for proximal LCX occlusions.
The operator needs to know methods to enhance the backup with a buddy-wire, or with anchoring balloons
[81, 82]. They are intended to improve and stabilise the guide catheter position in the ostium. In order of
increasing complexity, the respective methods are:
1. try to deeply engage the guide catheter without damage to the proximal vessel segments;
2. add a second wire introduced into a side branch proximal to the occlusion, preferably with a sti shaft
to increase support;
3. advance a second balloon into a side branch and in ate this balloon to trap the guide catheter during
advancement of the rst balloon through the occlusion;
4. use a guide catheter extension like the Heartrail™ catheter (Terumo Corp., Tokyo, Japan), the
Guideliner™ (Vascular Solutions Inc, Minneapolis, Minnesota, USA), Guidezilla™ (Boston Scienti c,
Natick, MA, USA), or Guidion™ (IMDS, Roden, The Netherlands).
The most commonly applied technique is the anchoring balloon (  Figure 15 (104_1368_ gure13.png) ). A
oppy wire is inserted into a side branch proximal to the occlusion, and then a balloon of su cient size is
advanced into this artery. Under sizing would lead to slipping out of the balloon and may cause dissection.
The balloon is then in ated to 8 to 10 atm (atmosphere) and kept in position during manipulation, balloon
passage and stent placement. Arrhythmias due to the balloon in ation are rarely seen, but if present would
then require intermittent de ation. In general, complications due to anchoring in RCA (right coronary artery)
side branches are unlikely. Using the anchoring in larger side branches of the left coronary artery may of
course lead to ischaemia. In the left coronary artery, a sti buddy wire in one of the larger arteries like an
Ironman™ (Abbott Vascular, Redwood City, CA, USA) may increase the support su ciently even without
balloon anchoring.
OVER-THE-WIRE OR (ODDS RATIO) MICROCATHETER APPROACH

The use of a support catheter or microcatheter with an over-the-wire (OTW) technique is strongly
recommended as it facilitates wire manipulation greatly (  Table 1 (104_1394_Table1.png) ). OTW (over-the-
wire) balloons would be an alternative provided the tip diameter is low. However, the tip marker of the
microcatheter is very close to the tip and identi es its position, whereas in OTW (over-the-wire) balloons the
marker is >10 mm (millimetre) from the tip so that the tip position within the occlusion is not absolutely sure.
The physical property of the balloon itself impairs the exibility of the tip, whereas a microcatheter shows a
uniform behaviour of the tip. The lumen within a microcatheter is slightly wider than that of an OTW-balloon,
which improves wire manipulation with less friction (  Figure 16 (104_1369_ gure14.png) ).
A sharp angled take-o of the occluded artery from the left coronary artery may require soft hydrophilic
wires to negotiate it, whereas the required angle and the wire sti ness will be inadequate to pass the
proximal cap of the occlusion. After advancement of a microcatheter to the proximal end of the CTO (chronic
total occlusion) a softer wire can then be exchanged for a dedicated recanalization wire without risk to the
protected proximal segment.


An important issue during advancement of a recanalization wire is the need for di erent tip shapes during
the course of wire advancement, and also the preservation of the tip shape which may get lost during a
lengthy procedure and needs to be modi ed or corrected. This can be easily checked and done with the help
of a microcatheter which is advanced into the proximal part of the occlusion or, in the case of long
occlusions, deeper into the occlusion.
Besides the straight low-pro le microcatheters, there are some support catheters with speci c designs to
help wire manipulation or which may be of assistance during the further course of a recanalization
procedure. One is the double lumen design, where one wire is guided through a central lumen in typical
OTW (over-the-wire) fashion, and a second wire port exits further proximally, with a shorter rapid exchange
lumen (Twin-Pass® [Vascular Solutions Inc, Minneapolis, Minnesota, USA], Crusader™ [Kaneka Corp, Osaka,
Japan]), FineDuo™ (Terumo Corp., Tokyo, Japan), Sasuke™ (ASAHI Intecc, Aichi, Japan). Another support
catheter is the Venture™ catheter (Vascular Solutions Inc, Minneapolis, Minnesota, USA) with a exible tip
that can be manipulated through a torque mechanism from the distal port of the catheter. This should
enable the operator to align and centre the wire towards an ostial occlusion of a side branch, for example a
sharp take-o of an occluded LCX. While the alignment may facilitate wire entry, the catheter is generally too
bulky to be advanced across the occlusion in the manner of a low-pro le microcatheter. Other support
catheters like the Tornus®, Corsair (both ASAHI Intecc, Aichi, Japan), and Turnpike™ (Vascular Solutions Inc,
Minneapolis, Minnesota, USA) are discussed later.
 FOCUS BOX 7
Catheter support for CTO (chronic total occlusion) PCI
Every e ort must be made to achieve good catheter support right at the beginning of the PCI
(percutaneous coronary intervention) in order to avoid later problems of balloon or stent
passage and dislodgment of the system
Aggressive catheter shapes should be used with care
Side hole catheters are advised, especially for the RCA
If a less aggressive shape is used, an increase of catheter diameter increases support
Long insertion sheaths can further enhance the catheter support
CATHETER EXCHANGE TECHNIQUES

With the above described approach to CTOs, after successful wire passage, the OTW (over-the-wire) catheter
or balloon needs to be exchanged for a rst or subsequent balloon for dilatation. This can be achieved by
the use of long wires from the beginning, or by dedicated extension wires. However, not all wires are
available in 300 cm (centimeter) length, and not all extension wires t all wires, and are not therefore
universally applicable. One technique to overcome this problem is the ushing out of the microcatheter. This
is easily done with a FineCross™ (Terumo Corp., Tokyo, Japan) or similar microcatheter, but may not always
be easily achieved in the case of guidewire kinking or multiple wires within the guide catheter. The simplest
method is just to place a 10cc saline lled syringe on the distal tip of the microcatheter with the distal 1cm of
the wire protruding. Then with manual force the syringe is compressed leading to release of the
microcatheter without moving the guidewire. The manual force can be reduced once the catheter is moving.
If this does not work, a balloon in ation device can be attached to the distal end of the microcatheter, and
under increasing pressure, up to 20atm, the catheter can be released. If this does not lead to active
movement of the catheter, it can be gently retracted under control of the wire position. The wire is held in
position by the pressure exerted on the microcatheter.
In case this does not work, or the operator is not sure about the security of the distal wire position, the safest
way to exchange a wire is the “trapping technique”: the microcatheter or OTW (over-the-wire) balloon is

moved back as far as possible until the distal 1cm of the guidewire is protruding from its end. Then a balloon
catheter is advanced without the need for a separate wire parallel to the microcatheter into the guide
catheter to be positioned distal to the distal end of the microcatheter, but within the guide catheter, usually
within the distal 3 to 4 cms. This balloon is in ated at 10 to 12 atm (atmosphere) thus trapping the guidewire
distal to the microcatheter, while the microcatheter can be safely retrieved without losing the wire position (
 Figure 17 (104_1370_ gure15.png) ). To achieve a su cient trapping e ect, a 2.0mm balloon is required
for a 6 or 7Fr guide and a 2.5 mm (millimetre) balloon for a 7 Fr or 8 Fr guide. This technique should also be
used to secure a sti bare guidewire when a microcatheter needs to be advanced over this wire without the
risk of inadvertent distal advancement of the wire.
A problem with this technique might be when the trapping balloon is not mounted on a wire but advanced
barely, that with low visibility of the radiopaque markers of the balloon, the advancement might be missed
on uoroscopy and the balloon pushed beyond the guide catheter tip into the coronary artery. To prevent
this, special trapping devices were developed and are available for both 90 and 100 cm (centimeter) catheter
lengths (Trapper™, Boston Scienti c, Natick, MA, USA; Trap-It™, IMDS, Roden, The Netherlands).
One should keep in mind that multiple wire and balloon exchanges and the above described techniques may
lead to a considerable loss of blood through the Y-connectors during the course of a long procedure. Y-
connectors designed to reduce blood loss are available and should be preferred.
GUIDEWIRE SELECTION AND HANDLING

Guidewire selection incorporates a great deal of personal preferences and experience. For a detailed
description of available wires see the 2007 EURO-CTO Club consensus document [3], and the update of 2012
[144], however, wires are continually developed and improved. There is no single wire that serves all lesions
and all circumstances, and a familiarity with several wires from each family is mandatory. Di erent operators
may prefer di erent wires and still achieve the same nal success, nothing is more important than the
predictability of the wire movement which comes with familiarity with the wire of your choice. Still there are
some general rules to wire selection, which are accepted by the majority of operators. One feature to
di erentiate wires is the construction principle of a spring coil wire or a PTFE (polytetra uorethylene)
coverage, also labelled plastic-jacket wire (  Table 2A (104_1395_Table2A.png) and  Table 2B
(104_1396_Table2B.png) ), but there are also wires which incorporate both principles like the PROGRESS wire
family (Abbott Vascular). Recently, ASAHI Intecc (Nagoya, Aichi, Japan) introduced a new family of wires based
on a new tip construction, the dual-core design, which enhances the torque control of the wire tip, and many
new variations of this design in new wires had been released. An additional new brand of wires was
introduced by Boston Scienti c with their range of Fighter, Samurai and Hornet wires of various tip
strengths.
In general for CTO (chronic total occlusion) recanalization, three features of the guidewire are of utmost
importance, the tip sti ness or penetration force, the ability to shape the tip and retention of the shape, and
above all the torque control. Penetration force is a combination of wire strength and tip diameter, it is
greatly increased with tapered tip wires (  Table 2A (104_1395_Table2A.png) ). Wires may be used in
incremental fashion with increasing tip sti ness when the previous wire encounters resistance. The torque
control is a major feature of dedicated CTO (chronic total occlusion) wires in order to facilitate manoeuvring
of the wire in long resistive lesions.
The wire selection depends on the planned approach to the occlusion, which is determined by the
angiographic features of the lesion. Initially, three technical approaches are discriminated, the “drilling
technique”, the “penetrating technique”, and the “sliding technique”. Each of them may be selected from the
onset according to the angiographic appearance of the occlusion and knowledge of the occlusion length, but
often needs to be changed during the procedure. Flexibility and adaptation of wire strategies is required
throughout the whole procedure ( Chapter 3.1 ).

Before the wire is advanced, the tip has to be shaped. This is the rst and basic step of wire manipulation,
and often requires modi cation during the progress of the procedure. In non-occlusive lesions a basic rule of
thumb is to adapt the radius of the tip angle to the size of the artery in which the wire is to be advanced. A
major di erence with tip shapes in CTOs is that the vessel diameter at the lesion site is practically zero.
Therefore, the length of the proximal tip angle is as short as possible with a moderate 30° to 45° angle. A
secondary angle is added about 5 mm (millimetre) distally to enable wire manipulation in the vessel segment
proximal to the occlusion, and to facilitate the tip engagement. These considerations apply in general to all
wire types and techniques in CTOs (  Figure 18 (104_1371_ gure16.png) ).
The drilling approach is ideal for occlusions with a distinct entry point. Typical wires for this approach are
moderately sti wires with high torque-control such as the Miracle Bros family of wires (ASAHI Intecc). The
tip diameter of these wires is 0.014” like normal workhorse wires, but the enforcement of tip strength is
incremental. The 3G wire provides more push than a softer oppy or PTFE (polytetra uorethylene) wire ( 
Figure 19 (104_1372_ gure17.png) ). Before the wider popularity of the Fielder XT wire (ASAHI Intecc) see
below, this was the initial wire of choice for many operators. A further development of this type of wire is the
Ultimate, which is comparable to the 3G, but due to a hydrophilic coating its penetration ability seems to be
enhanced.
With increasing strength of the wires from 3G to 12G or even 14G with the Hornet family the pushing force
could be adapted to the requirements of the lesion in case of problems with wire progress. The wire strength
cannot be increased by the aforementioned microcatheters, but the ease of manipulation will be improved
as the friction within the catheter is lower than within a long proximal arterial segment. The wire handling
with drilling consists of a very slow advancement of the wire into the occlusion with a turning movement on
the torque handle of less than 90° degrees in each direction in alternative directions. A new way to increase
the wire penetration force is achieved with a dual-lumen catheter mounted on a primary wire that might be
positioned in a side branch or went in a subintimal position, and a secondary wire is advanced through the
OTW (over-the-wire) lumen of that catheter.
The penetrating approach is ideal for occlusions without any discernible entry point, typically at the site of
side branches. The penetration requires smaller tip wires such as the Cross-it or more recent Progress wire
family (both Abbott Vascular) with 0.010" or less tip diameter, or the classic Con anza family of wires (ASAHI
Intecc) with 0.009" tip diameter. These wires provide increasing tip sti ness, and, except for the wire tip, with
additional hydrophilic coating to reduce friction of the wire and enhance the penetration force. In fact,
penetration into the subintimal vessel space may be frequent and therefore requires careful monitoring and
control of the wire approach. Often success is only achieved using the parallel wire approach with
penetrating wires (  Figure 20 (104_1373_ gure18.png) ).
The sliding technique rests on the low friction advancement of PTFE (polytetra uorethylene) wires and is
ideal for occlusions with suspected residual lumen or occlusion duration of less than 6 months. These wires
are widely (over)used, as they promise a fast approach because of the low friction, but the steerability is
limited especially with the Pilot™ (Abbott Vascular) and ChoICE® (Boston Scienti c) wire family and will easily
leave the vessel lumen. However, occasionally they can be used gently and carefully as an alternative
approach and will also be successful in crossing even complex looking occlusions. Arguably their more
e ective use is as a step-down option, once the proximal occlusion cap is passed e.g. (exempli gratia / for
example), by a Con anza wire, and the softer distal occlusion poses resistance to the advancement of the
shafts of the rigid wires, not to their tips. Exchange over a microcatheter is ideal in these cases (  Figure 21
(104_1374_ gure19.png) ). It cannot be emphasised enough that no single technique serves all lesions, and
all approaches should be utilised and combined as required.


The family of Gaia wires with the dual-core design and a unique pre-shaped miniature tapered tip provide an
additional dimension to wire manoeuvrability within CTO (chronic total occlusion) lesions. The principle of
handling these new wires with di erent wire tip strength between 1.7 and 4.5 g is based on visual control of
the wire tip on the uoroscopic image rather than rely on a tactile feedback. The torque control of these
wires is close to 1:1 and allows a redirection within the CTO (chronic total occlusion) body that is more
controlled than with previous wires. Many operators have included these wires already in their preferred
wire choice for both the antegrade and retrograde approach.
Soft tapered wires

A new development of the initial wire selection was inaugurated by the Fielder XT wire (ASAHI Intecc), which
deserves a special mention. (  Table 2B (104_1396_Table2B.png) ). Similar wires are now under
development or available from other manufactures. The Fielder XT consists of a PTFE
(polytetra uorethylene) coating, but the core provides a high torque control and the tip is tapered to 0.008”.
The tip welding is extremely short, allowing very short distal wire curves. It is very delicate and should be
advanced even slower and more gently than a regular PTFE (polytetra uorethylene) wire like the Whisper
(Abbott Vascular), Pilot , or Fielder wires. The tip shaping of this wire needs to be done very delicately and
gentle as the tip may be easily damaged. Furthermore, the wire should not be pushed and buckled within
the occlusion, as the tip may not be restored for a controlled guided advancement. Buckling of the wire tip is
done on purpose in some subintimal re-entry techniques (see below).
The Fielder XT can be basically applied using the sliding approach, but due to the tapered tip it may also
enter soft parts of a blunt proximal cap and help in the penetrating approach as well as in the drilling
approach. Inside the occlusion this soft wire with its delicate tapered tip may proceed within loose tissue
even in calci ed lesions (  Figure 15 (104_1368_ gure13.png) ).
There was a discussion as to whether this wire works because it can probe microchannels due to its smaller
tip diameter in relation to regular guidewires. However, no histological study has shown clearly traversing
microchannels. Experimental studies in animal models even suggest that microchannels are a feature of
early and recent occlusions but disappear in older occlusions where microchannels are unlikely to be found
[83]. A recent pathological analysis of the largest number of lesions, yet, even states that, microchannels are
rarely found in CTOs [137]. The fact, that this type of wire works so frequently as the rst and nally
successful wire is rather due to the fact that the soft tapered tip may track the loose tissue within the
occlusion body and therefore traverses the CTO (chronic total occlusion) without exiting subintimal.
The Fielder XT has the ability to frequently provide entry into the occlusion, and many experts are currently
using this wire as their rst line approach. The response to this wire dictates the next increment of tip force
and tip size.
This wire had been further re ned by incorporating the above-mentioned dual core design with the Fielder
XTA and the Fielder XTR, the latter with a reduced tip force also suitable for residual antegrade channels, and
it can navigate safely tiny collateral channels.
Parallel wire techniques

When true lumen wire passage fails, the rule is not to try with a wire that went subintimal too hard and too
long in order not to increase the size of the false lumen. Also avoid antegrade contrast injection and rely on
contralateral injections to avoid extension of dissections. The wire tip should not be advanced beyond more
than 5 mm (millimetre) to 10 mm (millimetre) extraluminal of the distal cap, but rather remain there and a
second wire can be inserted for the parallel wire technique.


The rst wire serves as a guide to the general direction of the vessel course and may enable the
manipulation of a second parallel wire slightly deviating from the initial course to successfully enter the distal
lumen. Often, the rst wire is a moderately sti wire, and the second wire is of increased sti ness, or
tapered (e.g., Miracle in combination with Con anza Pro). This technique can be accommodated by modern
6Fr guide catheters. However, if both wires are supported by a microcatheter or OTW (over-the-wire) balloon
(then termed the “see-saw technique”), a larger diameter of 7 Fr or 8 Fr is required. If necessary even a third
wire may be introduced. Now with advent of the Gaia wires, the Gaia 2 is often used as the primary wire in
these types of occlusions, and depending on the resistance within the occlusion is then combined in parallel
with a second Gaia 2 or a wire of incremental strength such as Gaia 3 or Con anza Pro.
The direction of the parallel wire manipulation is often misleading when looking on one imaging plane only.
A frequent change of view using orthogonal planes is advised. This may be a situation where a biplane
angiographic imaging with instant control of the wire position from two orthogonal views and repositioning
brings a major advantage over a monoplane angiographic system (  Figure 22 (104_1375_ gure21.png) ).
Deviation of the primary wire from the true vessel lumen may occur at every and any point during
advancement, but often it is at the entry of the occlusion with a large side branch where the wire deviates.
Sometimes, when an occlusion features several side branches, typically within the LCX with large obtuse
marginal branches, the wire can be directed only into one of the secondary branches. If, after some e ort,
this cannot be controlled, it may be prudent to dilate the occlusion towards this side branch with a small
sized balloon. Not infrequently, this manoeuvre then provides easy access to the other occluded branches
and is therefore termed the “open sesame” approach.
An important concept of this approach is the fact that a rst wire passed in the vicinity of the target within
the vessel structure will alter the conformity of the vessel. Especially long occlusions in the RCA (right
coronary artery) tend to collapse without a surrounding myocardial brace of the artery, unlike in an LAD (left
anterior descending) occlusion. This collapse and tortuous course of the original vessel is altered by a rst
wire. The second wire then runs along a changed anatomy and conformity of the vessel. Basically the same is
true when we work with two wires towards each other in the retrograde approach.
In parallel wire situations where the direction of the guidewire’s advancement is de ned, but the wire will
simply not penetrate the intended segment, the support of the wire needs enhancement. This can be
achieved by in ating an OTW (over-the-wire) balloon proximal to the occlusion, or by using other
enhancements of guide support such as the anchoring balloon technique or mother-in-child catheters.
In the past years the use of a dual-lumen catheter in this situation has gained wider use. This can improve
the parallel wire approach in many ways. One is that it atkes away the nedd to navigate the proximal section
were the rst wire already passed, provided that the catheter can be advanced. Therefore small diameter
catheters will be preferred. Another advantage is the increase of the wire control as the dual-lumen catheter
provides a much more stable position than a single lumen catheter.
With the advent of the retrograde technique, one needs to determine beforehand when to switch strategies
if the antegrade approach fails. The antegrade wire will remain in position when the retrograde probing
starts, but one will cut the parallel wiring attempts short if an alternative route is considered possible. If
there is the plan to use a retrograde approach, provided experience for that approach exists, not more than
20 to 25 minutes of uoroscopy time should be spent before deciding to switch to the retrograde approach.
 FOCUS BOX 8
Wiring strategy
Guidewire selection follows general rules which require adaptation to the individual situation
Soft tapered wires are preferred as the rst approach
A step-wise increase of penetration force is generally advised 
Occlusions without entry may require a sti penetrating wire

Within the occlusion a step-down to softer wires is advised
In case of a subintimal wire position, long probing should be avoided, and parallel wiring
chosen as the next step
ADVANCED TECHNIQUES
SUBINTIMAL RE-ENTRY TECHNIQUES

Di erent strategies to achieve re-entry have been developed, such as a brute force advancement of a wire
loop with the aim of gaining distal re-entry, but with the high risk of shearing o possibly important side
branches (subintimal tracking and re-entry (STAR) technique) [84, 85]. Variations of this technique include a
more limited dissection using a sti wire to penetrate the lesion, then reverting to a soft wire, typically the
Fielder FC (functional class) (ASAHI Intecc) for a controlled re-entry without shearing o side branches. This
approach had been developed by Alfredo Galassi and termed the mini-STAR technique.
More controlled approaches include the attempt to re-enter with sti and tapered wires with or without the
assistance of IVUS (intravascular ultrasound) - a method with limited success; or variations of the controlled
antegrade and retrograde subintimal tracking technique (CART). [86, 87, 88, 89]. This requires a retrograde
wire passage through collateral channels to be combined with an antegrade wire advancement, and with
either proximal or distal (retrograde) advancement of balloon catheters and dilatation to create local
dissections to facilitate a wire re-entry into the true lumen. The combined antegrade and retrograde
procedures in particular require long procedure times, and increased radiation.
Guided subintimal re-entry

A new family of devices (Bridgepoint Medical Inc. Plymouth, MN, USA) make a guided controlled re-entry
from the subintimal position into the true lumen possible. They consist of a blunt tipped catheter to either
pass the occlusion or at least create a subintimal entry (CrossBoss™), a at shaped balloon with side exit
holes (Stingray™ catheter), and the appropriate small diameter wire with an angled and sharpened tip
(Stingray guidewire) to exit from these holes and re-enter the true lumen. These are the rst set of tools
speci cally designed to facilitate controlled subintimal re-entry into the true lumen distal to a coronary
occlusion. After an extensive series of in vitro evaluations, and the rst in man application to test this
approach, the German and US FAST-CTO (Facilitated Antegrade Steering Technique for the treatment of
Chronic Total Occlusions) studies were designed to show the feasibility of the device used in the hands of
dedicated experts in the eld of treating CTOs. While this approach of directed penetration of the subintimal
layer towards the true lumen with a needle is already well established in the treatment of peripheral arterial
occlusions of the super cial femoral artery [90, 91]. In the smaller dimension of the coronary arterial system,
no such dedicated device had been available. Now, the Bridgepoint devices make this guided re-entry
feasible in the coronaries and provide a unique addition to the technical approach to CTOs.
There is certainly a learning curve to utilise these devices to their full potential. In the initial German study,
device success in initially failed cases was about 67%[168]; in the later and larger US trial, the success rate
was increased to 80%[169]. The major cause of a failed re-entry was the loss of distal contrast lling because
of extension of the subintimal space by a dissection and compression of the distal true lumen. This can be
overcome by several techniques to either avoid contrast lling or retrieve already accumulated contrast
through OTW (over-the-wire) catheters[170]. Another problem was a failure to direct the re-entry wire
towards a very small distal target lumen[171]. A major determinant of success is the ability to advance the
Stingray balloon far enough parallel to the distal lumen to a vessel segment with minimal angulation, which
is imporved by a new balloon generation of StingRay LP (Boston Scienti c)[172]. Further experience has now
 
improved the bailout success as shown in the example in (  Figure 23 (104_1376_ gure22.png) ). In some
parts of the world the Stingray based directed re-entry has become an established tool mainly as a bailout
strategy together with the retrograde options, as demonstrated in the RECHARGE registry[173].
THE RETROGRADE APPROACH

The idea to approach an occluded artery from the distal vessel segment originates from the initial
experience of Geo Hartzler who used a saphenous vein graft to open a native coronary artery from the
reverse side. Large collateral connections are observed in some patients, and the ability to use these large
arterioles as access was explored by Osamu Katoh [92]. A wider application only became possible with
re ned tools such as soft tipped wires and microcatheters to be advanced through collateral channels.
Initially, dilatation of the septal channel was shown to be a possible way to enlarge the access route safely, as
these channels are surrounded by tissue, and injury may not lead to tamponade, which is a more imminent
risk with epicardial channels.
The technique requires speci c wire and balloon equipment, and should only be undertaken after training or
instruction with an experienced operator. This complex method is applicable when it is deemed possible to
pass a wire to the CTO (chronic total occlusion) from the collateral donor artery retrogradely towards the
distal aspect of the vessel (e.g., a septal branch or an epicardial vessel). The steps involved include the
passage of a soft polymer-coated wire via the retrograde collateral into the distal vessel which is then
steered proximally to approach the distal cap of the occlusion retrogradely.
The retrograde system will be disengaged only at the end of the procedure if the wire is externalised. If an
antegrade wire is advanced and the procedure is to be concluded via this course, the retrograde system
should be retrieved as early as possible, but also as late as necessary. There may be situations, when the
occlusion of the RCA (right coronary artery) includes the crux, and bifurcation stenting of the crux is required,
having a “marker” in one of the distal branches from the retrograde approach may come in handy. In any
instance, after retrieval of the retrograde system, a nal injection should be done into the retrograde guiding
catheter to ensure the integrity of the collateral pathway and the donor segment.
ASSESSING COLLATERAL PATHWAYS

The review of cases with an unsuccessful antegrade approach suggests that suitable retrograde collaterals
are present in more than 50% of cases but this percentage may be an underestimate if an assessment with
supra-selective injection with a microcatheter of the most promising collaterals is performed, or if dedicated
equipment o ers safe instrumentation of very tortuous epicardial collaterals.
The rst and most important step when considering the retrograde approach is the angiographic
visualisation of the collateral pathways. There are more than 20 individual pathways described [93], but for
the sake of the interventional approach, the basic division into septal and epicardial connections is su cient.
For a perfect visualisation it is important to avoid panning during the injection and lming, and to allow
enough time for the contrast medium to reach the occluded segment.
Among the important features for the assessment of a possible suitable route for wire access to the distal
occluded segment is the diameter of the collateral connections. This was initially graded in 3 categories of
collateral connection size (CC) (CC0: no angiographic continuous connection; CC1: threadlike connection
(<0.4mm); CC2: side branch like connection (>0.4mm)) [67] (  Figure 24 (104_1377_ gure23.png) ). There
are also occasional large connections especially via the apex of >1mm diameter which could be labelled CC3
connections. Other important features to consider are the tortuosity of the connection and the angle of
takeo from the donor segment, as well as the site of entry into the receiving segment. A collateral


connection should enter the receiving segment far enough away from the occlusion site to allow the
alignment of the wire and support catheter within the distal segment for the retrograde penetration of the
occlusion.
A score integrating these important factors was suggested which, however, cannot account for the operator’s
experience, which is the most important factor in determining whether a collateral can be used as a so called
“interventional collateral” (REF McEnt).
The assessment also has to take into account that several collateral pathways may coexist, and that their
appearance may change depending on the haemodynamic status of the collateral donor artery [67].
Therefore, any previous angiograms should be carefully analysed. Disappearance of a collateral connection
between two angiograms at di erent time points may not signify the actual closure of the collateral
connection, but rather its dormant function. In some situations, a low pressure balloon occlusion of one of
the pathways may be used to explore alternative routes, which are more likely for a wire passage. Careful
wire probing may still achieve wire passage (  Figure 25 (104_1378_ gure24.png) ). If septal and epicardial
collaterals coexist, the septal pathway should be preferred because it is dilatable channel for device passage,
and it is often the shorter connection. A large apical connection between the LAD (left anterior descending)
and posterior descending coronary artery (PDA) may look promising because of its size, but the additional
length of this way around the apex may cause problems due to the limited length of available catheters, and
by the fact that the push around the apex is limited. The selection of collaterals is also dependent on the
available wire and support catheters, and there has been considerable development during the past few
years which has changed the approach considerably. However, one should keep in mind, that perforation of
an epicardial collateral will inevitably be more problematic to control than damage to an intraseptal
collateral pathway.
 FOCUS BOX 9
Expertise requirements for retrograde technique
The retrograde recanalisation technique should only be conducted by experienced
operators
Speci c care needs to be taken to avoid damage to the collateral donor artery
Careful planning is required including the use of short (ended) guiding catheters
The operator needs to be familiar with the di erent retrograde techniques: -Marker wire
Retrograde wire crossing
CART
Reverse CART
Wire externalisation
Intravascular ultrasound should be available for retrograde procedures
WIRE AND DEVICE CROSSING OF COLLATERALS

After identi cation of a possible collateral access to the distal collateral bed, the wire passage needs careful
planning. The passage of the wire and the support catheters, or other devices like balloon catheters, requires
considerable support by the guiding catheter to be advanced through the collateral channel. Therefore a
large catheter (7 Fr) is advantageous for the retrograde approach. If an ipsilateral collateral should be used
for a retrograde approach e.g. (exempli gratia / for example), an epicardial connection between LCX and
diagonal branches or vice versa, an 8Fr size is preferable to allow for a wire passage around the collateral
back into the guiding catheter. A shortened guiding catheter of 90cm length is preferable which is available
from many vendors; otherwise the catheter needs to be shortened on-site.


A general rule for the retrograde approach is that extreme caution is necessary to avoid any damage to the
collateral donor vessels. Such a procedure may be long, and the position of a catheter through the left main
and LAD (left anterior descending) through the septum for access to the RCA (right coronary artery) may
impede perfusion by its shear diameter. Therefore, pre-existing lesions in the donor artery may require
treatment before the retrograde access is attempted. Damage by the catheter tip directly, and thrombus
formation must be avoided. Careful monitoring of the catheter tip position and frequent checking of the
anticoagulatory e ect of heparin by activated clotting time (ACT) are mandatory.
The wire used for passage through septal or epicardial collaterals needs to be soft-tipped and steerable, and
is usually supported by a microcatheter. Initially the choice of wire for collateral passage relied on already
available non-dedicated wires such as the Whisper® ES (Abbott Vascular) and the Fielder FC (functional class)
(ASAHI Intecc).
Now dedicated wires for collateral passage are available and have replaced previous wires almost
completely. They are the Sion family of wires (ASAHI Intecc) again based on the dual-core design. The tip
strength is less than 1g, and they are non-tapered. The Sion is hydrophilic, whereas the Sion Black is
additionally coated with PTFE (polytetra uorethylene). The Sion Blue on the other hand is hydrophobic and
not as ideal for passing tiny tortuous collateral channel. These Sion wires have widened the possibility to
approach even epicardial collaterals which previously were considered to delicate for a wire passage. For the
tiniest of collaterals the Fielder XTR can be tried, but the tip support is very low which may pose a problem
once the wire needs to be followed with a microcatheter. Recently an additional wire was introduced with a
very low tip load of 0.3 g speci cally able to pass wven the most tortuous segments with a low probability of
collateral damage, the Suoh03 (ASAHI Intecc). This wire is a further addition of the wire arsenal for collateral
passage.
Septal sur ng or selective injection are two basic approaches to cross septal collaterals, typically from the
LAD (left anterior descending) to the RCA (right coronary artery). They are often the topic of dispute
eventhough they should and can be used next to each other in daily practice. There are simple prerequisites
which can decide the preferred approach depending on the collateral anatomy. A general use of septal
sur ng lead to perforation in 25% of all attempted collaterals[174], whereas an open mind takes all the
options. If there is a large CC2 straight collateral connection, this will be passed straightforward with a Sion
wire without the need for further con rmation, as a reference image will be su cient to guide the
advancement. If there is a high degree of tortuosity in a septal it is wise to inject contrast through collateral
microcatheter after aspirating blood, to elucidate possible obstacles like branches and kinks in the collateral
course. Then a Sion or Suoh03 can be used gently to overcome these obstacles, whereas sur ng would have
the risk of dissecting the collateral at these sensible way points. On the other hand, if we have not well
de ned connections despite a septal branch that goes deep and typical into the septum, we may assume
small tiny connections that are often rather straight. Here septal sur ng with a Sion Black provides often
surprisingly easy and straight connections to the PDA by probing the possible routes without contrast
guidance. The operator relies on his tactile feedback of low resistance in a connection as opposed to tight
friction if the wire enters myocardium. The otherway round from the PDA to the LAD (left anterior
descending) may be less likely to work with septal sur ng, as the tortuous bent opart of the septal collateral
is closest to the PDA, and this needs to be overcome before then the wire enters the straighter segment
towards the LAD (left anterior descending). Therefore visulaization of the entry point of the PDA collateral is
often required. Sur ng is not advised for epicardial connections, where we must have a precise idea of the
collateral course, best obtained in multiple viewing angles.
A basic rule is the need for careful shaping of the wire tip, except for the Suoh03 which comes with a very
small preshaped tip that should not be further altered. The shape of the Sion wires to be used within the
be required. To make these tip changes possible, a microcatheter is mandatory. The preferred device for the

should be a smallest possible short tip of 45 to 60°, but in retro ecting collateral bends even a 90° angle may

collateral passage is the septal dilator catheter (Corsair or Corsair Pro; ASAHI Intecc), but occasionally also
the FineCross MG (Terumo), can pass where the Corsair fails to cross, due to its sleek design (  Figure 25
(104_1378_ gure24.png) ). The range of microcatheters available for the retrograde approach has increased
over the past years with additional devices from Vascular Solutions, the so called Turnpike and Turnpike LP
microcatheters.
Before the availability of these microcatheters active balloon dilatation of the septal channel was required to
facilitate the catheter passage (  Figure 26 (104_1379_ gure25.png) ). This may still be necessary, and
requires small balloon diameters of 1.0 mm (millimetre) to 1.25 mm (millimetre) diameters. The rapid
exchange (RX) type can be used as the hypo-tube part of the balloon catheter does not enter into the septal
channel. Low pressure in ations of 3 to 4 atm (atmosphere) are su cient to dilate the channel and allow a
catheter passage. If a distal dilatation within the occluded segment is required from the retrograde
approach, where the balloon is further advanced, an OTW (over-the-wire) balloon should be preferred to
avoid damage of the collaterals by the hypotube segment.
The development of the Corsair catheter changed this approach considerably, as its soft narrow tip
supported by a strong catheter shaft with metal support allows the gradual advancement and dilatation of
the septal channel without the need for balloon predilatation. It is slowly “screwed” through the collateral
channel and reaches the distal coronary bed of the occluded artery. It facilitates wire exchanges and, with
more supportive wires, further advancement even into the occlusion itself. Unlike a microcatheter it will not
move gradually backwards out of the collateral by the beating heart movement, which inevitably occurs with
unsupported wires, and may also happen with a FineCross catheter.
The use of the Corsair septal dilator also may facilitate device passage through epicardial channels, though
these channels require speci c care in order to avoid overstretching and damage. Especially those channels
on the epicardial surface from the diagonal to the marginal branches and vice versa may be better passed
with the Finecross, as this catheter enforces less strain upon the collateral channel. The problem of the
epicardial catheter passage has been improved by the introduction of the much softer and sleeker Caravel
microcatheter (ASAHI Intecc) which should be now the preferred microcatheter in these settings.
The patient may experience chest pain during the retrograde procedure and this technique needs careful
attention to the potential causes of this ischaemia. If possible, the largest and most important collateral
connection should not be used for retrograde access, but rather a smaller (and often less tortuous)
connection in order not to impair perfusion to the occluded territory for the duration of the procedure.
Furthermore, there is the risk of spasm or dissection in the donor artery if there are pre-existing lesions. If
no major obstruction is detected, the procedure may be continued despite the discomfort of the patient, and
analgesia should be applied.
 FOCUS BOX 10
Techniques for retrograde approach

Retrograde facilitation of antegrade wire crossing:
Marker wire
Kissing wire
True retrograde wire crossing:
Intraluminal retrograde wire passage
Subintimal wire passage with controlled re-entry (reverse CART / classic CART)
MARKER AND KISSING WIRE APPROACH



The marker-wire or kissing-wire approach can be used to facilitate the antegrade wire direction. It may be a
good way to become familiar with the retrograde wire passage without applying the complex procedural
extension described below. One major advantage of placing a marker wire in the distal occlusion cap is that
no additional contrast injection is needed during the manipulation of the antegrade wire. The distal marker
serves as an ideal target to direct the antegrade wire (  Figure 27 (104_1380_ gure26.png) ). In patients
with severely impaired renal function with a low limit of contrast allowance, such an approach may help to
keep contrast use as low as possible.
In situations where the microcatheter cannot follow the collateral wire, for example in very tortuous
epicardial collaterals, the marker wire approach may be the only way to overcome the occlusion and should
not be forgotten as a valuable technical option.
RETROGRADE WIRE CROSSING

The ideal course of a retrograde approach would be the retrograde wire crossing from the distal true lumen
into the true lumen proximal of the occlusion. The direct penetration of the distal brous cap may be easier
than the penetration of the more resistant proximal cap. The ideal platform to attempt this will be the
positioning of a support catheter (Corsair, Caravel, Turnpike) in the segment close to the distal cap. Then the
wire selection can be similar to that of the antegrade approach, although one must consider the translational
movement of the heart which may cause considerable instability of the micorcatheter tip. In these
conditions, a “heavier” wire like an Ultimate may be better controllable for the retrograde passage.
Occasionally stronger support is required, but if this does not lead to advancement within the lumen, entry
of a dissection plane is likely which then requires a change of strategy. A valuable addition for retrograde
directe wireing are the Gaia family of wires. One could start with a soft Gaia 1, however, in most instances
the length of the passage way from the guide catheter through the microcatheter to the distal cap makes a
rather strong wire preferable such as the Gaia 3.
If a true lumen wire passage is achieved, the next step is to dilate the occlusion. Theoretically this could be
achieved by advancing an OTW (over-the-wire) balloon retrogradely to create a small lumen, but the push
support is very limited; it can be increased once the retrograde wire is trapped within the antegrade guiding
catheter. The retrograde support catheter can then advance retrogradely through the occlusion and thus
create a small lumen for the passage of the antegrade wire. In most cases an externalisation of a RG3 wire
will follow which then provides excellent support and also guide catheter control. If this retrograde passage
is not possible, an attempt can be made to advance a recanalization wire antegradely alongside the
retrograde wire. The use of support catheters, however, is to be preferred as the most successful mode. If
externalisation of the retrograde wire is not planned for some reason, one could also advance the support
catheter into the antegrade guiding catheter, then remove the retrograde wire, and attempt to direct an
antegrade wire into the distal ori ce of the retrograde support catheter, thus facilitating antegrade wire
passage (rendezvous or tip-in technique) [94].
CART, REVERSE CART

When the antegrade or retrograde wire enters a false lumen, a CART-technique can be used [86]. The basic
principle of the technique will be described, but for further and detailed study one should refer to the
various case reports published on this topic [86, 89, 95, 96, 97, 98, 99, 100, 101]], and recent more detailed
overviews [145, 146]. The technique is still developing as evident from the fact that the original CART
(controlled antegrade and retrograde subintimal tracking) technique is now less frequently applied than the
reverse CART (controlled antegrade and retrograde subintimal tracking) technique [77, 102].


The basic principle is Dr Katoh’s concept of creating a connection between a wire located in a dissection
plane, with the true lumen distal (CART) or proximal (reverse CART (controlled antegrade and retrograde
subintimal tracking)) of the occlusion (  Figure 28 (104_1381_ gure27.png) ). This technique requires both
an antegrade and retrograde wire positioned within the occlusion; one wire is advanced to meet the other
wire but fails to achieve position within the same plane. The wires need to be parallel within the occlusion at
some point, then a balloon is advanced to dilate at the site where one of the wires is presumably entering
into a dissection. This balloon can be advanced via the collateral (CART) (  Figure 29
(104_1382_ gure28.png) ) or from the antegrade side (reverse CART (controlled antegrade and retrograde
subintimal tracking)) (  Figure 30 (104_1383_ gure29.png)), and needs to dilate within the occlusion. This
may require a gradual increase of balloon size to allow its passage, as for the successful wire re-entry into
the true lumen; the in ated balloon diameter needs to be big enough to create a dissection. To assess the
optimum balloon diameter, intravascular ultrasound (IVUS) may be used for imaging. IVUS (intravascular
ultrasound) is preferred over repeated contrast injections as the latter may create an unnecessary extension
of the intended dissection, and provides an inferior assessment of the true vessel size as compared to the
ultrasound approach.
For a typical reverse CART (controlled antegrade and retrograde subintimal tracking) approach the balloon
remains partly in ated during the retrograde attempt to pass the wire along the balloon into the proximal
true lumen. If this is not achieved, placement of an IVUS (intravascular ultrasound) catheter helps to locate
the position of the distal wire and to direct it into the proximal true lumen. Which wire to use depends on the
morphology of the occlusion, such as the calcium content and resistance to the wire. Several wires may be
attempted, such as a soft PTFE (polytetra uorethylene) with a looped wire, which is termed knuckle wire
passage, or a Ultimate or the sti er Con anza Pro wire. Torque control and penetration force is the reason
for a speci c wire selection and must be adapted to the individual situation. In calci c lesions a Pilot 200 wire
may be of help, preferably without resorting to the knuckling, but in case of failed passage, knuckling may
help.
The knuckle wire approach increases the rate and extent of subintimal dissection as compared to the
classical wire based reverse CART (controlled antegrade and retrograde subintimal tracking) procedure. In
the latter approach a subintimal pathway was actually found only in about 25% of the retrograde cases in a
Japanese study [147]. The extent of subintimal passage may be much higher when the retrograde dissection
approach, popular in the US and UK, is applied, as demonstrated in a recent IVUS (intravascular ultrasound)
study with upto 90% of subintimal passage with the retrograde technique[175]. This approach uses the
retrograden and antegrade knuckle wire (preferably a Fielder XT or Pilot 200 wire) more extensively and
increases thus the extent of subintimal pathways. There lies also a misinterpretation of technical sdetails of
the retrograde approach within the so called hybrid approach[176]. In this algorithm the retrograde
technique is termed retrograde dissection re-entry, and set synonymous with reverse CART (controlled
antegrade and retrograde subintimal tracking), whereas the reverse CART (controlled antegrade and
retrograde subintimal tracking) technique on the contrary tries to stay within the plaque[145]. In fact, the
most important concept of the CART (controlled antegrade and retrograde subintimal tracking) technique is
not to create a subintimal dissection, but to create space within the body of the occlusion. The crossing of
the wire from the distal true lumen to the proximal true lumen should happen within the occlusive plaque,
and therefore it is mandatory to advance the antegrade wire far enough distal to allow the antegrade
balloon passage into this are for creating the space for re-entry [145]. A frequent mistake is, that the
retrograde wire is passed beyond the proximal cap into the subintimal space, and the exit from this space
into the true lumen in a vessel segment with only little plaque may be near to impossible. In such a situation,
the point of re-entry must be moved further distal into the body of the occlusion. If this is achieved, the rate
of subintimal stent placement will be low.


A recent expert group tried to de ne the evolving concepts of the reverse CART (controlled antegrade and
retrograde subintimal tracking) technique with new more precise terms[177]. We may speak of the
conventional reverse CART (controlled antegrade and retrograde subintimal tracking) technique with a larger
balloon being the target when a retrograde wire was advanced far into the CTO (chronic total occlusion)
body. On the other hand we have the directed reverse CRT, where the concept is to advance a wire
antegardely as far as possible, advance a rather small balloon of 2 to 2.5mm, and use this as a target from
retrograde. This concept works best with the new wires of the Gaia type, which provide excellent torque
control. Finally a third type would be the extended reverse CART (controlled antegrade and retrograde
subintimal tracking) technique, when the operator fails to penetrate the proximal cap, but can advance the
retrograde wire far proximal, and then the connection is done close to but proximal of the proximal cap. 
Figure 31 (104_3489_FigureX3.jpg) shows the main features of these basic types.
RETROGRADE DISSECTION REENTRY

As mentioned above, this approach is favoured in some countries as part of the hybrid algorithm [151]. The
idea behind this use of a knuckle wire technique to connect the antegrade and retrograde wires is that it may
be quicker than a wire based careful probing towards an antegrade or retrograde wire target. Whether this
idea holds true is ywet to be tested. However, it is important to know also this kind of approach, as it may be
the only safe way to explore long occlusions typically of the right coronary artery, where the course of the
vessel may remain unclear, and often tortuous. The advantage of a knuckled wire like the Fielder XT is, that it
is unlikely to penetrate the adventitia and rather follows the course of the main vessel. Likewise, many
calci ed lesions will be overcome only by going around the calcium with this knuckle wire approach.
WIRE EXTERNALISATION
Once the retrograde wire is passed into the true proximal vessel lumen, the next step is to facilitate balloon
passage. Several methods have been described above, however, the most straightforward technique that
yields the best support for balloon and stent advancement is externalisation of the wire, i.e. (id est / that is),
passage of the retrograde wire into the antegrade guiding catheter and further out of the catheter through
the Y-connector. To make this possible, rst of all the wire length is a limitation that needs to be
accommodated for by careful initial planning, then the collaterals need to be protected from the sti er part
of the wire, and the retrograde guiding catheter position needs to be controlled at all times to avoid it being
sucked into the artery and causing damage.
The advantage of an externalised wire is especially valuable in cases of ostial or very proximal occlusions of
the RCA (right coronary artery) where the guiding catheter needs to be pushed out of the ostium for optimal
stent placement. If the guiding catheter is controlled on an externalised wire, its` position cannot be lost as
would be the case if it depended on an antegrade wire only (  Figure 32 (104_1384_ gure30.png)).
One precaution which helps to make this technique possible is the use of short guiding catheters preferably
both for the antegrade and retrograde access (e.g., available at 90 cm (centimeter) length as Launcher®,
Medtronic, Minneapolis, MN, USA). In addition, the externalised wire needs to be a wire of 300cm length or
longer with moderate sti ness in the shaft to make the push out possible. In general, the previously used
long Fielder FC (functional class) and XT wires (ASAHI Intecc) are completely replaced by the 330 cm
(centimeter) long dedicated externalisation wire (ASAHI Intecc). But even with this extra length in long
collateral pathways, especially via the apex, and in tall patients where a 90cm guide is not possible, the
externalisation process may become di cult. A trick is to use guide catheter extensions (Guideliner™,
Guidezilla™, Guidion™) to allow the entry into the antegrade guide catheter deeper within the vessel, and
the trapping technique is then applied within this guide extension.


If the wire can be advanced retrogradely into the guiding catheter lumen it can be trapped there and the
retrograde support catheter pushed into the guiding catheter. From there, the guidewire can be exchanged
for a 300 cm (centimeter) or longer soft wire, which is then pushed out from the other side of the catheter.
Any balloon or stent can then be advanced reversely over this wire. Before the devices can be advanced, the
retrograde support catheter needs to be moved back from the guiding catheter to make room for the
antegrade devices. It needs to be moved back distal to the segment where the most distal stent will be
placed, but it needs to be kept across the full course of the collateral pathway to protect it from the sti part
of the externalised wire. This move back procedure for disengaging the support catheter may often take
some time, especially if it is a Corsair or Turnpike catheter. It can be achieved by gradual pull while turning
the micorcatheter. A FineCross™ catheter will be easier to retrieve on the one hand, but it needs more care
not to pull it back too far as it does not keep its position as stable as a Corsair. The newer Caravel catheter
has features between Finecross and Caravel, it should not be turned like a Corsair, as the tip is more fragile,
but it provides a more stable position than the Finecross. During this pullback manoeuvre, the tip of the
retrograde guiding catheter must be kept out of the coronary ori ce to avoid deep and forceful engagement.
There is no problem in keeping the guiding catheter far out in the aorta as the support is maintained by the
Corsair catheter.
In ostial occlusions especially of the RCA (right coronary artery), intubation of the coronary artery from the
antegrade approach may be di cult and not always in alignment with the vessel course which makes the
retrograde access into the catheter lumen di cult. In these instances, the wire can be advanced into the
aortic root and caught by a snare through the antegrade guiding catheter. One popular and easy to use
snares is the ENSnare (Merit Medical, South Jordan UT, US). The snaring of the wire can be made easier when
the wire and the snare are advanced into the right brachiocephalic artery, as there the space for the wire to
escape the snare is reduced. There is one caution for the snaring approach. When a sti wire is snared, this
wire cannot be exchanged. But it can be used as a purchase to advance then the microcatheter into the
aortic root. As the next step, the sti wire needs to be released from the catheter that holds the snare, again.
Subsequently a soft wire, typically the 330cm or longer externalization wire is then advanced and then again
snared to be pulled through and out of the antegrade guide catheter. The snared tip of the externalization
wire must be cut with a scissor and then ballons and stents advanced from the antegrade side.
 FOCUS BOX 11
The systematic step-by-step retrograde approach

Analyse the collateral pathways
Advance antegrade wire as far as possible
Collateral wire passage, followed by microcatheter passage
Advance retrograde wire to achieve long overlap with antegrade wire (if true lumen wire
passage is not possible)
Dilate the occlusion site from antegrade with incremental balloon size
Use IVUS (intravascular ultrasound) if unsure about the vessel dimension to adjust proper
balloon size
Pass the retrograde wire along the antegrade balloon into the proximal segment
Enter the antegrade guiding catheter and trap the wire to follow with the microcatheter
Exchange for externalization wire
Retreat the microcatheter into the distal vessel segment, but keep the collateral pathway
always protected by this catheter
Before removal of the retrograde catheter always check the integrity of the collateral
pathway


FOLLOWING THE WIRE WITH DEVICES
BALLOON DILATATION
After the guidewire has been successfully advanced across the occlusion, and most importantly, its correct
intravascular position checked on at least two orthogonal views with a contralateral injection, a balloon
needs to be advanced. This is achieved with low-pro le1 mm (millimetre) to 1.25 mm (millimetre) balloons,
which are then followed by an adequately sized balloon. Several suppliers provide dedicated balloons and
operators need to become familiar with these (e.g., MiniTrek™ (Abbott Vascular), Tazuna® (Terumo),
Sprinter Legend® (Medtronic), Falcon CTO (chronic total occlusion) (Invatec), Sapphire Pro II® (Orbus-Neich))
(  Table 3 (104_1397_Table3.png) ). It needs to be mentioned that the diameter on the balloon labels of
these speciality balloons is not related to device success, as the shape of the tip, the transition from tip to
balloon, and the backup provided by the hypotube shaft will determine balloon passage, not a small nominal
balloon diameter. With modern day low-pro le balloons, there is no advantage regarding balloon passage
for an OTW-balloon over a rapid-exchange monorail catheter system, rather the improved hypotube shaft of
a rapid-exchange monorail catheter will transmit the applied pushing force better than the combination of
the guidewire and the OTW (over-the-wire) tube.
Resistance to balloon advancement results in a backing out of the guide catheter from the ostium of the
coronary artery. If even a small balloon cannot be advanced, there are several techniques available to
increase support which are described above (guide catheter selection).
ALTERNATIVE TECHNIQUES TO PASS A RESISTANT OCCLUSION

In some instances with heavily calci ed lesions a rotablator is required. However, it may be extremely
di cult to exchange the recanalization wire for the delicate 0.010" rotablator guidewire which is extremely
di cult to manipulate in complex coronary lesions. Wire exchange is made possible by advancing a
microcatheter as far as possible into the occlusion in a wedge position, then removing the recanalization
wire and advancing the RotaWire gently. Once achieved, a small rotablator burr may then be advanced.
Another speci c device useful in this situation would be the Excimer® laser catheter (Spectranetics Inc.,
Colorado Springs, CO, USA), but due to high hardware costs and limited applications these devices are rarely
found in coronary catheterisation labs today. [103, 104]. A new device which may help to prepare the lesion
for balloon passage through the occlusion is the Tornus support catheter (ASAHI Intecc), which can be
advanced over the guidewire across the occlusion in an anti-clockwise screwing movement [105] (  Figure
33 (104_1385_ gure31.png) ). If there is no evidence of severe calci cation, the Corsair catheter (ASAHI
Intecc) , originally developed for the retrograde approach, can be used as an antegrade support catheter and
may achieve lesion passage in balloon-resistant lesions.
STENT PLACEMENT
After the initial balloon passage with a small balloon, the selection of the proper size of balloon for
subsequent full lesion dilatation may be di cult, this also holds true for the selection of the proper stent
size. Therefore, intra-coronary nitroglycerine is given to increase the distal vessel size which is always
constricted after the recanalization. As with the collateral supply, the existing pressure had been in the range
of 30 mmHg to 40 mmHg, and the vasodilatory response to the increased antegrade pressure takes time and
may lead to underestimation of actual distal vessel diameters. The balloon length is chosen to facilitate the
subsequent stent advancement. Stent implantation is mandatory in CTOs though there may be rare
exceptions in very small vessels and short occlusions, where a stent is not implanted. However, the question
arises as to the functional relevance of these CTOs in secondary small coronary arteries.


There is a clear indication to use DES (drug-eluting stent) in CTOs to ensure a high long-term patency which
has been proven by numerous registry studies [106, 107, 108, 109, 110, 111, 112, 113, 114] and nally also by
randomised trials [115, 116, 117] (  Figure 34A (104_1386_ gure32a.png) and  Figure 34B
(104_1387_ gure32b.png)). A speci c problem of balloon angioplasty and later BMS (bare metal stent)
implantation was the high reocclusion rate [21, 72]. This di culty seems to have been almost overcome by
the use of DES (drug-eluting stent) (  Figure 35A (104_1388_ gure33a.png) and  Figure 35B
(104_1389_ gure33b.png) ). and recent amendments to guidelines have given a clear indication for their use
[34]. The need for long and multiple stents no longer appears to have a considerable impact on vessel
patency, although very late stent thrombosis in this speci c lesion subset maybe more frequent than with
BMS (bare metal stent), at least with the rst generation DES (drug-eluting stent) used in the initial studies
[23]. After balloon dilatation of a CTO (chronic total occlusion), it may be advantageous to employ a liberal
stent coverage with maximised stent expansion in order to avoid focal restenosis at the edges of the stent(s)
when they are implanted within severely atherosclerotic segments, and to reduce ow turbulence to reduce
the risk of stent thrombosis. There is no strong evidence for this advice, and support by prospective studies
is needed.
The disadvantage of extensive stent placement is the continued loss of vessel conformity by this so-called
“full metal jacket”. This may lead to stent fractures and increased rate of restenosis or even reocclusions.
This phenomen is reported with rst generation DES (drug-eluting stent) [148, 149], but probably not
uncommon with more recent DES (drug-eluting stent). It might be less detected because of the thinner stent
struts with lower radiopacity (  Figure 36 (104_2685_ gure33_update.jpg) ).
The future development will tend towards the use of fully bioresorbable vascular sca olds in CTOs, but the
current experience is limited to less complex CTOs, and experienced a sewtback with the removal of the rst
generation BRS from the market. However, in small intial studies the concept of BRS in CTOs provided some
encouraging results [150][178, 179, 180, 181, 182]. Despite the withdrawal from the market we should expect
a revival in the future with newer generations of BRS especially for younger patients with little or no
calci cations (  Figure 37 (104_2686_ gure34_update.jpg) ).
 FOCUS BOX 12
Tips and tricks for successful device crossing
Device passage through a CTO (chronic total occlusion) can be improved by:
Optimum guiding catheter support
Low pro le balloons
Anchoring balloon technique
Preparation with a Tornus or Corsair catheter
Rotablation should be available
THE ROLE OF IMAGING IN CTO PCI
INTRAVASCULAR ULTRASOUND IN CTOS.

Intravascular ultrasound (IVUS) can be of use during several steps of the interventional process[183]. As an
advanced adjunctive technique requiring considerable expertise and experience, it may be used to locate the
entry into an occlusion if a side branch takes o right at the proximal cap [118, 119], and the IVUS
(intravascular ultrasound) can be positioned at the take-o of this side branch (  Figure 36
(104_2685_ gure33_update.jpg) ). If the guidewire is advanced into the subintimal space, an IVUS
(intravascular ultrasound) catheter advanced into this false space may help facilitate re-entry into the true
lumen [120], again a technique only for the experienced. 

Where IVUS (intravascular ultrasound) may be of general advantage is the assessment of stent placement
and optimised stent expansion [121, 122]. Full lesion coverage and expansion may be key factors to obtain
persistent long-term success in these lesions. Especially in situations where a subintimal passage of the wire
is present with distal re-entry, the location of the subintimal passage is important in order to nd the right
location for stent placement to ensure full coverage of the subintimal wire course (  Figure 39
(104_1391_ gure35.png) ). A further potential impact on facilitating successful wire passage could be brought
about by the introduction of a forward-looking IVUS (intravascular ultrasound), which might help to select
the proper entry point for penetration of the proximal occlusion cap ( Chapter 2.11
(/eurointervention/textbook/pcr-textbook/chapter/?chapter_id=89) ).
MULTISLICE CT (COMPUTED TOMOGRAPHY) ( CHAPTER 2.3

It would be ideal to have a clear roadmap of the vessel course of an occluded artery. Especially in a long
occluded RCA (right coronary artery) which often has a tortuous course, angiography fails to give an idea of
the true vessel course, except when spots of calcium are present within the presumed vessel course.
Furthermore, it would be helpful to identify problem zones within a calci ed occlusion where the wire may
be deviated into the subintimal space by dense calcium. Multislice computed tomography (MSCT) of a
coronary artery with high-resolution acquisition systems may be helpful in these situations; preliminary
experience is limited but is gaining interest. Initially the presence of calcium was con rmed as the main
cause of procedural failure [123, 124, 125]. The di erentiation between occlusive calci ed plaque as opposed
to calcium within the vessel wall may help select patients who may still have a good chance for wire passage.
Unlike peripheral artery disease where the concept of roadmaps is easily applicable even within the
angiography system, the heart is moving both with the heart beat and with respiration. Therefore a perfect
overlay will not be possible in the near future. However, the idea of an overlay of a roadmap created by
MSCT (multislice computed tomography) may help to assess the presumed wire course and improve the
procedural success [126] (  Figure 40 (104_1392_ gure36.png) ). Initial steps towards this goal are being
attempted by industry and research groups[184].
WHEN TO STOP A CTO PROCEDURE
BASIC RULES OF DISENGAGEMENT

An important question during PCI (percutaneous coronary intervention) of a CTO (chronic total occlusion) is
when to stop the procedure, often to opt for a subsequent second attempt or to consider the patient best
treated by surgical revascularisation, especially when other non-occlusive lesions require further attention. A
typical reason to stop the procedure is a severe dissection with loss of distal target visualisation because of a
subintimal haematoma. A retrograde approach may still be possible, but generally a second attempt after
resolution of the dissection will be the best approach. There is no systematic study on the time required for
resolution of a dissection, it may happen as early as the next day, but for the sake of radiation and contrast
safety, a longer delay is a wise decision.
THE CONCEPT OF A SECOND ATTEMPT OR (ODDS RATIO) STAGED APPROACH

The operator should always consider a second attempt as a possible option if severe dissections occur or
obstruction of collateral ow to the distal target make the guidance of the wire impossible. The success rate
of a second attempt, with the lessons learned during the rst approach in mind, is very high in experienced


hands. For the safety of the procedure, and above all to prevent radiation and contrast damage to the
patient, the deferral of the procedure is sound advice to consider.
AVOIDING AND MANAGING COMPLICATIONS

The published data show no di erence in the complication rates between occlusive and non-occlusive
lesions, and this seems to hold true also for advanced techniques and new dedicated guidewires [1, 74, 77] (
 Figure 41 (104_1393_ gure37.png) ). In view of the often disputed indication to re-canalise a CTO (chronic
total occlusion), and the viable option of surgical revascularisation, the interventional procedure must be
kept a safe procedure.
Some complications are typical for a CTO (chronic total occlusion) procedure, such as perforating a vessel
during wire advancement, but this is harmless as long as it is correctly recognised. Therefore every care must
be taken to recognise and correct false wire positions, and never to follow these wires with a balloon without
absolute certainty of correct intraluminal wire position. Dissections and perforations may lead to contrast
staining of the myocardium, which is not necessarily a reason to stop the procedure as long as it does not
compromise the collateral vessel supply.
Pericardial tamponade is the feared acute complication, which occurs rarely when the above mentioned
rules are followed closely [127, 128]. During the procedure all other anticoagulants except heparin (which
can be readily reversed by protamine sulphate) should be avoided. However, in the case of heparin induced
thrombocytopenia, the short-acting agent bivalirudin could be an alternative [129]. There is no data to
support the use of glycoprotein IIb/IIIa antagonists in CTOs.
In the situation of a wire perforation with the danger of pericardial tamponade the operator needs to be
experienced in placing a pericardial drain if needed; often this can be avoided by rapidly obstructing the
leakage with a balloon in ated for several (more than 10) minutes to seal the damage. If this does not work,
negative pressure suction on a microcatheter advanced far into the distal vessel may help, or thrombus
injection, coil placement or microspheres through this microcatheter. The problem will be di cult to control
if the leakage is fed not only by the antegrade course, but also via collaterals. In this situation reversal of
heparin anticoagulation with protamine sulphate and a pericardial drainage for some time may be the only
option, and in the case of continuing e usion, a surgical repair.
Before PCI (percutaneous coronary intervention) for a CTO (chronic total occlusion) is attempted, one needs
to be familiar with at least with one e cient technique to deal with perforation. Most important is to have
the distal wire tip always in view, and to watch carefully for signs of perforation. Other complications which
have been observed are damage in icted on neighbouring vessels during the approach towards the
occlusion. Here particular care is required as damage with partial vessel occlusion may put the patient at
severe risk as one artery is already chronically occluded. Sti wires should not be advanced through the left
main artery across angles to avoid such damage, but rather they should be advanced through OTW (over-
the-wire) catheters which are put into position with the help of regular oppy guidewires.
RADIATION AND CONTRAST INDUCED COMPLICATIONS

A major concern with the above described complex procedural techniques is the in iction of radiation and
contrast medium induced complications. Some of the risk can be reduced pre-emptively by realising the
problem early on. Radiation safety is a part of interventional training, and it especially needs to be applied
during procedures like CTO (chronic total occlusion) PCI (percutaneous coronary intervention). Limiting the
eld of view with collimation is most important, and extra e ort should be made to adapt the eld frequently
during the procedure. During the course of the wire progress, the eld needs to be adapted, later on during
a procedure the eld needs to include the position of the wire tip, and a larger eld may be helpful. Filming 
should be limited to the minimum necessary for the wire progress, as it increases radiation dose by several
factors as compared to uoroscopy. Radiation will run typically into 40 to 60 min uoroscopic time,
sometimes even longer. To avoid radiation damage to the patient’s skin, collimation should be used
whenever possible and the angulation must be changed and adjusted frequently to avoid a single spot
radiation [130, 131]. That these factors can be controlled and are mainly in uenced by the operator was
demonstrated in complex PCI (percutaneous coronary intervention) and CTO (chronic total occlusion)
procedures [132]. The limiting factor in a procedure should not be the uoroscopy time but the e ective
dose, and this can be in uenced by the operator early on during the procedure. If the total radiation dose
exceeds certain limits (e.g., 5 Gy (gray)) the patient needs to be advised and informed of possible delayed
skin reactions, and further counselling should be arranged. Reporting of the radiation dose, either as
e ective patient dose (air Kerma in mGy) or dose area product (in cGycm2) or both, to the regulatory
authorities is required in many countries. Modern X-ray equipment allows us to reduce radiation to levels
that lie at a fraction of the doses reported in the early experience of complex CTO (chronic total occlusion)
PCI[185].
Like the radiation exposure, contrast usage is also greatly in uenced by the operator. Limits of maximum
contrast volume for each individual patient should be pre-speci ed according to the glomerular ltration
rate (GFR) before the PCI (percutaneous coronary intervention). The maximum amount of contrast for each
individual patient should be set before the start of the procedure with respect to the patient’s age and
kidney function. A rule of thumb is to limit contrast to four times the GFR (glomerular ltration rate) [133,
135]. The contrast use can be reduced by using smaller guide catheters and diagnostic catheters for
contralateral injections, and in critical patients this may be an indication to use the retrograde marker wire
technique to avoid repetitive contrast injections during wire manipulation. As a precaution uid hydration
should be applied liberally before and during a CTO (chronic total occlusion) procedure. The indication for
the retrograde approach may be based on the need for limited contrast use, as it requires less contrast once
the wire is passed through the collateral channel. Furthermore, IVUS (intravascular ultrasound) can be used
from the time of balloon in ation to stent implantation to make any contrast injection unnecessary [136].
 FOCUS BOX 13
Prevention of complications during CTO (chronic total occlusion) PCI
Complications of CTO (chronic total occlusion) PCI (percutaneous coronary intervention)
should be not more severe than with elective PCI (percutaneous coronary intervention) in
stable angina
Total control of the wire position prevents perforation and tamponade
Frequent monitoring of anticoagulation prevents thrombus formation in the collateral donor
artery
Limiting the radiation eld reduces radiation exposure
Liberal hydration prevents contrast induced nephropathy
Contrast use can be reduced by IVUS
Stopping the procedure when reaching radiation and contrast limits is required
Always consider the option of a second attempt
CONCLUSIONS
Advancements in the percutaneous revascularisation of a CTO (chronic total occlusion), both in the primary
procedural success and in the long-term vessel patency, have led to a change in our perspective of this
speci c complex coronary lesion subset. In recent guidelines the indication for PCI (percutaneous coronary
intervention) is identical to any other coronary lesion in stable angina pectoris, requiring certain symptoms
or ischaemia. In addition, viability must be present for PCI (percutaneous coronary intervention) in post-MI
CTOs, which can be assessed by cardiac MRI (magnetic resonance imaging). The improvement in procedural
success is due to improved devices and modi ed techniques which need to be followed. The speci c
subtleties of these antegrade and retrograde techniques require further specialisation on the part of
interventional cardiologists in order to obtain su cient experience.
PERSONAL PERSPECTIVE - GERALD S. WERNER

The treatment of a CTO (chronic total occlusion) is often called the last frontier of coronary interventions,
implying that frontiers need to be explored and crossed. However, this must not lead to an irresponsible
attitude towards the patient, and a competition among operators for the most daring technical approaches.
The safety of the patient must the foremost priority of the operator, and PCI (percutaneous coronary
intervention) needs to be undertaken within the limits of this prerequisite. Any of these advanced techniques
require familiarisation with all aspects of possible complications, and a continuous experience. Within each
interventional programme, the treatment of complex CTOs should be restricted to one or two expert
operators, and only those with a high work load should advance further to the more complex techniques of
the retrograde approach. The retrograde approach to a CTO (chronic total occlusion) carries the risk of
in icting damage to the donor artery, and therefore should never be the principal routine approach.
Following this recommendation, it will become possible to o er PCI (percutaneous coronary intervention) as
the principal revascularisation approach to a CTO (chronic total occlusion), with a success rate close to the
range achieved in non-occlusive lesions. as well as a continuous workload to achieve the highest possible
success rate. Once the occlusion is crossed, new balloon and support devices facilitate lesion preparation for
a subsequent and obligatory implantation of DES(s). The procedure is aided by additional imaging modalities
like intravascular ultrasound and may also be facilitated by preprocedural MSCT (multislice computed
tomography). In the face of these advances, procedural safety needs to be the main objective. Since patients
are treated for symptomatic relief, without evidence so far of a prognostic bene t as seen in most patients
with stable angina pectoris, the complication rate must remain low and possible complications need to be
managed by the operator without sequelae for the patient. After the success rate in CTOs has reached levels
well beyond 90%, the focus in the future will be to maintain a durable result. Despite the recent setbacks
with bioresorbable sca olds, they still hold the promise to overcome the issue of full metal jacketed arteries
with stent fracture and possible late stent occlusions after DES (drug-eluting stent) implantation, and the
dream of full biological reconstitution of the artery may come true with new generations of these BRS.
 REFERENCES
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12/2/2018 The PCR-EAPCI Textbook - Chronic total occlusions

PART III CHAPTER 13

CHRONIC TOTAL OCCLUSIONS

DEFINITION AND CLASSIFICATION

RATIONALE FOR INDICATIONS

THE PREVALENCE OF CHRONIC TOTAL OCCLUSIONS IN CORONARY ARTERY

Fibrous proximal cap

RATIONALE FOR TREATMENT

Improvement of LV (left ventricle) function

Complete revascularisation in multivessel disease

Evidence from randomized trials

THE FUNCTIONAL CAPACITY OF COLLATERALS

Collaterals may prevent MI when an occlusion develops gradually

INDICATION FOR CTO (CHRONIC TOTAL OCCLUSION) PCI (PERCUTANEOUS

HOW TO APPROACH A CTO

OPERATOR EXPERIENCE AND TRAINING ( CHAPTER 4.10

The European Association of Percutaneous Cardiovascular Interventions (EAPCI) published, in 2005, a

CHOOSING THE MOST APPROPRIATE STRATEGY FOR A CTO

PCI of CTOs should be performed by specially trained operators

GUIDE CATHETER SUPPORT ( CHAPTER 3.1

OVER-THE-WIRE OR (ODDS RATIO) MICROCATHETER APPROACH

CATHETER EXCHANGE TECHNIQUES

GUIDEWIRE SELECTION AND HANDLING

Soft tapered wires

Parallel wire techniques

Occlusions without entry may require a sti penetrating wire

SUBINTIMAL RE-ENTRY TECHNIQUES

Guided subintimal re-entry

THE RETROGRADE APPROACH

ASSESSING COLLATERAL PATHWAYS

WIRE AND DEVICE CROSSING OF COLLATERALS

Techniques for retrograde approach

MARKER AND KISSING WIRE APPROACH

RETROGRADE WIRE CROSSING

CART, REVERSE CART

RETROGRADE DISSECTION REENTRY

The systematic step-by-step retrograde approach

FOLLOWING THE WIRE WITH DEVICES

ALTERNATIVE TECHNIQUES TO PASS A RESISTANT OCCLUSION

THE ROLE OF IMAGING IN CTO PCI

INTRAVASCULAR ULTRASOUND IN CTOS.

MULTISLICE CT (COMPUTED TOMOGRAPHY) ( CHAPTER 2.3

WHEN TO STOP A CTO PROCEDURE

BASIC RULES OF DISENGAGEMENT

THE CONCEPT OF A SECOND ATTEMPT OR (ODDS RATIO) STAGED APPROACH

AVOIDING AND MANAGING COMPLICATIONS

RADIATION AND CONTRAST INDUCED COMPLICATIONS

PERSONAL PERSPECTIVE - GERALD S. WERNER

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