Algorithmic solutions to common problems encountered during chronic total occlusion angioplasty: The algorithms within the algorithm

Abstract

Improved technical equipment, dissemination of best practices, and the importance of complete coronary revascularization have led to a renewed interest in coronary chronic total occlusion (CTO) PCI. In particular, the hybrid algorithm has been associated with increasing procedural success rates in the US. However, the hybrid algorithm only covers overarching strategies in the overall approach to these lesions. Several technical challenges can occur during execution of these approaches, each of which has several potential solutions. A systematic or algorithmic approach to dealing with these challenges could contribute to improved procedural efficiency and higher procedural success. While there have been isolated attempts in the past to codify approaches to each of these situations, there has not been a contemporary, comprehensive review of the potential solutions to these problems. We present 10 common problems encountered during CTO PCI and a consensus hierarchical approach to them. K E Y W O R D S consensus, percutaneous coronary intervention, solutions The hybrid algorithm for selecting crossing strategies for coronary chronic total occlusions (CTOs) was initially reported in 2012 via consensus of high volume CTO PCI operators (Figure 1) 1 . In essence, the algorithm is predicated on four angiographic features seen on dual catheter angiography: (1) anatomy of the lesion's proximal and distal caps, (2) anatomy of the vessel distal to the lesion's distal cap, (3) the presence of useable collaterals, and (4) the length of the lesion occlusion segment. The first three inform the operator whether to start

Successful revascularization of right coronary artery chronic total occlusion by the antegrade and retrograde approaches

“…In the present patient, although the segment of RCA occlusion was long and the proximal cap was ambiguous, the "antegrade preparation first" philosophy was prompted (2). The parallel wire technique and wire escalation is the basic technique of the antegrade approach.…”

“…Chronic total occlusion (CTO) recanalization of coronary arteries remains one of the most challenging procedures in interventional cardiology, despite the availability of new specialized guidewires, microcatheters, and dedicated devices, as well as many sophisticated techniques for crossing occluded arteries and the widespread use of drugeluting stents (DES) (1,2). Successful CTO percutaneous coronary intervention (PCI) has been associated with better long-term outcomes and an improvement in mortality, left ventricular function and quality of life (3).…”

Coronary lithotripsy for failed rotational atherectomy, cutting balloon, scoring balloon, and ultra‐high‐pressure non‐compliant balloon

“…According to that algorithm, ELCA could have been a valid tool in such a case for plaque modification, although not available in our institute. Moreover, subintimal lesion crossing and NC balloon plaque “crushing,” similar to the so called “external cap crush” technique for uncrossable lesions could have been attempted at the time of CTO PCI …”

Training in high‐risk coronary procedures and interventions: Recommendations for core competencies

“…While CTO‐PCI proctoring has been shown to increase success rates, case complexity and volume during an advanced training year allows this skillset to be learned systematically despite a condensed time period 25 . The hybrid algorithm stresses the importance of flexibility and having multiple approaches to achieve revascularization 26 . As lesion complexity increases, more technically challenging approaches such as ADR (Antegrade Dissection/Reentry) and retrograde CTO‐PCI may be required to achieve high procedural/technical success rates 18,20,27 .…”