Successful revascularisation of chronic total occlusions (CTOs) remains one of the greatest challenges in the
era of contemporary percutaneous coronary intervention (PCI). Such lesions are encountered with increasing frequency in
current clinical practice. A predictable increase in the future burden of CTO management can be anticipated given the
ageing population, increased rates of renal failure, graft failure and diabetes mellitus. Given recent advances and developments
in CTO PCI management, successful recanalisation can be anticipated in the majority of procedures undertaken
at high-volume centres when performed by expert operators.
Despite advances in device technology, the management of resistant, calcific lesions remains one of the greatest challenges
in successful CTO intervention. Established techniques to modify calcific lesions include the use of high-pressure
non-compliant balloon dilation, cutting-balloons, anchor balloons and high speed rotational atherectomy (HSRA). Novel
approaches have proven to be safe and technically feasible where standard approaches have failed. A step-wise progression
of strategies is demonstrated, from well-recognised techniques to techniques that should only be considered when
standard manoeuvres have proven unsuccessful. These methods will be described in the setting of clinical examples and
include use of very high-pressure non-compliant balloon dilation, intentional balloon rupture with vessel dissection or balloon
assisted micro-dissection (BAM), excimer coronary laser atherectomy (ECLA) and use of HSRA in various ‘offlabel’
settings.
6a Oswald GA, Yudkin iS. The relative contribution ofundiagnosed diabetes mellitus and "stress" to hyperglycaemia following acute myocardial infarction. Diabetic Medicine (m press).
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