A New Algorithm for Crossing Chronic Total Occlusions From the Asia Pacific Chronic Total Occlusion Club
Journal
JACC: Cardiovascular Interventions
Journal Volume
10
Journal Issue
21
Pages
2135-2143
Date Issued
2017
Author(s)
Abstract
Although the hybrid chronic total occlusion (CTO) algorithm had many excellent recommendations, there has been infrequent adoption in the Asia Pacific region. The Asia Pacific CTO club propose an algorithm for case selection based on the Japan-CTO score and a new CTO algorithm, which is applicable globally. This algorithm allows for differing skill sets and equipment availability and contains practical teaching for CTO percutaneous coronary intervention. Similar to the hybrid algorithm there are 3 main questions that determine whether the primary approach is antegrade or retrograde: 1) is there proximal cap ambiguity; 2) is the distal vessel of poor quality; and 3) are there interventional collaterals present. In contrast to the hybrid algorithm occlusion length alone does not determine the choice of either a wire escalation strategy or a dissection re-entry strategy. Rather a combination of factors including ambiguity of the vessel course, severe calcification, tortuosity, length, and previous failure are used to determine this. The role of intravascular ultrasound–guided entry to overcome proximal cap ambiguity and the CrossBoss catheter in occlusive in-stent restenosis are highlighted in the algorithm. Both the parallel wire technique and dissection re-entry with the Stingray system have been included as options when the initial antegrade wire passage fails. Intravascular ultrasound–guided wiring along with limited subintimal tracking and re-entry are included as final options in the algorithm. Finally, the algorithm incorporates guidance on when to stop the procedure. It is hoped that this algorithm will serve as the basis for future CTO percutaneous coronary intervention proctoring and training. ? 2017 American College of Cardiology Foundation
Subjects
chronic; coronary; intervention; occlusion; percutaneous; revascularization
SDGs
Other Subjects
algorithm; antegrade dissection; chronic total occlusion; coronary angiography; dissection; human; in-stent restenosis; intravascular ultrasound; Japan CTO score; percutaneous coronary intervention; priority journal; Review; scoring system; Asia; chronic disease; clinical competence; clinical decision making; coronary artery occlusion; decision support system; decision tree; diagnostic imaging; interventional ultrasonography; medical society; percutaneous coronary intervention; predictive value; procedures; restenosis; risk assessment; risk factor; treatment outcome; Algorithms; Asia; Chronic Disease; Clinical Competence; Clinical Decision-Making; Coronary Angiography; Coronary Occlusion; Coronary Restenosis; Decision Support Techniques; Decision Trees; Humans; Percutaneous Coronary Intervention; Predictive Value of Tests; Risk Assessment; Risk Factors; Societies, Medical; Treatment Outcome; Ultrasonography, Interventional
Publisher
Elsevier Inc.
Type
review