Guiding Principles for Chronic Total Occlusion Percutaneous Coronary Intervention: A Global Expert Consensus Document
Journal
Circulation
Journal Volume
140
Journal Issue
5
Pages
420-433
Date Issued
2019
Author(s)
Brilakis E.S.
Mashayekhi K.
Tsuchikane E.
Abi Rafeh N.
Alaswad K.
Araya M.
Avran A.
Azzalini L.
Babunashvili A.M.
Bayani B.
Bhindi R.
Boudou N.
Boukhris M.
Božinović . Ž.
Bryniarski L.
Bufe A.
Buller C.E.
Burke M.N.
Büttner H.J.
Cardoso P.
Carlino M.
Christiansen E.H.
Colombo A.
Croce K.
Damas De Los Santos F.
De Martini T.
Dens J.
DI Mario C.
Dou K.
Egred M.
Elguindy A.M.
Escaned J.
Furkalo S.
Gagnor A.
Galassi A.R.
Garbo R.
Ge J.
Goel P.K.
Goktekin O.
Grancini L.
Grantham J.A.
Hanratty C.
Harb S.
Harding S.A.
Henriques J.P.S.
Hill J.M.
Jaffer F.A.
Jang Y.
Jussila R.
Kalnins A.
Kalyanasundaram A.
Kandzari D.E.
Karmpaliotis D.
Kassem H.H.
Knaapen P.
Kornowski R.
Krestyaninov O.
Kumar A.V.G.
Laanmets P.
Lamelas P.
Lee S.-W.
Lefevre T.
Li Y.
Lim S.-T.
Lo S.
Lombardi W.
McEntegart M.
Munawar M.
Navarro Lecaro J.A.
Ngo H.M.
Nicholson W.
Olivecrona G.K.
Padilla L.
Postu M.
Quadros A.
Quesada F.H.
Prakasa Rao V.S.
Reifart N.
Saghatelyan M.
Santiago R.
Sianos G.
Smith E.
Spratt J.C.
Stone G.W.
Strange J.W.
Tammam K.
Ungi I.
Vo M.
Vu V.H.
Walsh S.
Werner G.S.
Wollmuth J.R.
Wu E.B.
Wyman R.M.
Xu B.
Yamane M.
Ybarra L.F.
Yeh R.W.
Zhang Q.
Rinfret S.
Abstract
Outcomes of chronic total occlusion (CTO) percutaneous coronary intervention (PCI) have improved because of advancements in equipment and techniques. With global collaboration and knowledge sharing, we have identified 7 common principles that are widely accepted as best practices for CTO-PCI. 1. Ischemic symptom improvement is the primary indication for CTO-PCI. 2. Dual coronary angiography and in-depth and structured review of the angiogram (and, if available, coronary computed tomography angiography) are key for planning and safely performing CTO-PCI. 3. Use of a microcatheter is essential for optimal guidewire manipulation and exchanges. 4. Antegrade wiring, antegrade dissection and reentry, and the retrograde approach are all complementary and necessary crossing strategies. Antegrade wiring is the most common initial technique, whereas retrograde and antegrade dissection and reentry are often required for more complex CTOs. 5. If the initially selected crossing strategy fails, efficient change to an alternative crossing technique increases the likelihood of eventual PCI success, shortens procedure time, and lowers radiation and contrast use. 6. Specific CTO-PCI expertise and volume and the availability of specialized equipment will increase the likelihood of crossing success and facilitate prevention and management of complications, such as perforation. 7. Meticulous attention to lesion preparation and stenting technique, often requiring intracoronary imaging, is required to ensure optimum stent expansion and minimize the risk of short- and long-term adverse events. These principles have been widely adopted by experienced CTO-PCI operators and centers currently achieving high success and acceptable complication rates. Outcomes are less optimal at less experienced centers, highlighting the need for broader adoption of the aforementioned 7 guiding principles along with the development of additional simple and safe CTO crossing and revascularization strategies through ongoing research, education, and training. ? 2019 American Heart Association, Inc.
Subjects
coronary occlusion; methods; outcome; percutaneous coronary intervention; treatment
SDGs
Other Subjects
angiography; chronic total occlusion; computed tomographic angiography; consensus; coronary angiography; fluoroscopy; human; patient history of coronary artery bypass graft; percutaneous coronary intervention; physician; priority journal; radiation dose; Review; skin injury; stent thrombosis; chronic disease; collateral circulation; coronary artery occlusion; coronary blood vessel; diagnostic imaging; percutaneous coronary intervention; physiology; practice guideline; procedures; treatment outcome; Chronic Disease; Collateral Circulation; Coronary Angiography; Coronary Occlusion; Coronary Vessels; Humans; Percutaneous Coronary Intervention; Practice Guidelines as Topic; Treatment Outcome
Publisher
Lippincott Williams and Wilkins
Type
review