Current Cardiology Reports

, 15:334 | Cite as

Chronic Total Occlusions: Patient Selection and Overview of Advanced Techniques

  • Santiago Garcia
  • Shuaib Abdullah
  • Subhash Banerjee
  • Emmanouil S. Brilakis
Interventional Cardiology (S Rao, Section Editor)
Part of the following topical collections:
  1. Topical Collection on Interventional Cardiology


Percutaneous treatment of coronary chronic total occlusions (CTOs) remains challenging, mainly due to difficulty in crossing the lesion. However tremendous progress has been achieved recently with expanded use of the retrograde approach and advanced dissection re-entry techniques. The development of the “hybrid” approach from North American operators has provided practical recommendations on how to select initial and subsequent CTO crossing strategies. Moreover, additional information has emerged on the frequency of CTOs among patients undergoing cardiac catheterization and on the adverse prognostic impact of CTOs on clinical outcomes of patients with ischemic cardiomyopathy who have implantable cardioverter defibrillators. Overall, CTO interventions remain a dynamic area with multiple novel technical and clinical developments.


Chronic total occlusion Coronary revascularization Percutaneous coronary intervention 

Supplementary material

11886_2012_334_MOESM1_ESM.mpg (3.9 mb)
ESM 1(MPG 4035 kb)
11886_2012_334_MOESM2_ESM.mpg (2.4 mb)
ESM 2(MPG 2455 kb)


Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. 1.
    Di Mario C, Werner GS, Sianos G, et al. European perspective in the recanalisation of Chronic Total Occlusions (CTO): consensus document from the EuroCTO Club. EuroIntervention. 2007;3(1):30–43.PubMedGoogle Scholar
  2. 2.
    Hochman JS, Lamas GA, Buller CE, et al. Coronary intervention for persistent occlusion after myocardial infarction. N Engl J Med. 2006;355(23):2395–407.PubMedCrossRefGoogle Scholar
  3. 3.
    Fefer P, Knudtson ML, Cheema AN, et al. Current perspectives on coronary chronic total occlusions: the Canadian Multicenter Chronic Total Occlusions Registry. J Am Coll Cardiol. 2012;59(11):991–7.PubMedCrossRefGoogle Scholar
  4. 4.
    Levine GN, Bates ER, Blankenship JC, et al. ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention. A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Society for Cardiovascular Angiography and Interventions. J Am Coll Cardiol. 2011;58(24):e44–122.PubMedCrossRefGoogle Scholar
  5. 5.
    •• Joyal D, Afilalo J, Rinfret S. Effectiveness of recanalization of chronic total occlusions: a systematic review and meta-analysis. Am Heart J. 2010;160(1):179–87. This is a meta-analysis of 13 studies comparing clinical outcomes of successful vs. failed CTO recanalization.PubMedCrossRefGoogle Scholar
  6. 6.
    Baks T, van Geuns RJ, Duncker DJ, et al. Prediction of left ventricular function after drug-eluting stent implantation for chronic total coronary occlusions. J Am Coll Cardiol. 2006;47(4):721–5.PubMedCrossRefGoogle Scholar
  7. 7.
    Kirschbaum SW, Baks T, van den Ent M, et al. Evaluation of left ventricular function three years after percutaneous recanalization of chronic total coronary occlusions. Am J Cardiol. 2008;101(2):179–85.PubMedCrossRefGoogle Scholar
  8. 8.
    Melchior JP, Meier B, Urban P, et al. Percutaneous transluminal coronary angioplasty for chronic total coronary arterial occlusion. Am J Cardiol. 1987;59(6):535–8.PubMedCrossRefGoogle Scholar
  9. 9.
    Danchin N, Angioi M, Cador R, et al. Effect of late percutaneous angioplastic recanalization of total coronary artery occlusion on left ventricular remodeling, ejection fraction, and regional wall motion. Am J Cardiol. 1996;78(7):729–35.PubMedCrossRefGoogle Scholar
  10. 10.
    Van Belle E, Blouard P, McFadden EP, Lablanche JM, Bauters C, Bertrand ME. Effects of stenting of recent or chronic coronary occlusions on late vessel patency and left ventricular function. Am J Cardiol. 1997;80(9):1150–4.PubMedCrossRefGoogle Scholar
  11. 11.
    Sirnes PA, Myreng Y, Molstad P, Bonarjee V, Golf S. Improvement in left ventricular ejection fraction and wall motion after successful recanalization of chronic coronary occlusions. Eur Heart J. 1998;19(2):273–81.PubMedCrossRefGoogle Scholar
  12. 12.
    Piscione F, Galasso G, De Luca G, et al. Late reopening of an occluded infarct related artery improves left ventricular function and long term clinical outcome. Heart. 2005;91(5):646–51.PubMedCrossRefGoogle Scholar
  13. 13.
    Cheng AS, Selvanayagam JB, Jerosch-Herold M, et al. Percutaneous treatment of chronic total coronary occlusions improves regional hyperemic myocardial blood flow and contractility: insights from quantitative cardiovascular magnetic resonance imaging. JACC Cardiovasc Interv. 2008;1(1):44–53.PubMedCrossRefGoogle Scholar
  14. 14.
    Werner GS, Surber R, Kuethe F, et al. Collaterals and the recovery of left ventricular function after recanalization of a chronic total coronary occlusion. Am Heart J. 2005;149(1):129–37.PubMedCrossRefGoogle Scholar
  15. 15.
    • Nombela-Franco L, Mitroi CD, Fernandez-Lozano I, et al. Ventricular arrhythmias among implantable cardioverter-defibrillator recipients for primary prevention: impact of chronic total coronary occlusion (VACTO Primary Study). Circ Arrhythm Electrophysiol. 2012;5(1):147–54. This study shows higher risk for appropriate shocks and death among patients with implantable cardioverter defibrillators who had a CTO vs. those who did not.PubMedCrossRefGoogle Scholar
  16. 16.
    Claessen BE, van der Schaaf RJ, Verouden NJ, et al. Evaluation of the effect of a concurrent chronic total occlusion on long-term mortality and left ventricular function in patients after primary percutaneous coronary intervention. JACC Cardiovasc Interv. 2009;2(11):1128–34.PubMedCrossRefGoogle Scholar
  17. 17.
    Claessen BE, Dangas GD, Weisz G, et al. Prognostic impact of a chronic total occlusion in a non-infarct-related artery in patients with ST-segment elevation myocardial infarction: 3-year results from the HORIZONS-AMI trial. Eur Heart J. 2012;33(6):768–75.PubMedCrossRefGoogle Scholar
  18. 18.
    Yang ZK, Zhang RY, Hu J, Zhang Q, Ding FH, Shen WF. Impact of successful staged revascularization of a chronic total occlusion in the non-infarct-related artery on long-term outcome in patients with acute ST-segment elevation myocardial infarction. Int J Cardiol. Aug 25 2011.Google Scholar
  19. 19.
    van der Schaaf RJ, Claessen BE, Hoebers LP, et al. Rationale and design of EXPLORE: a randomized, prospective, multicenter trial investigating the impact of recanalization of a chronic total occlusion on left ventricular function in patients after primary percutaneous coronary intervention for acute ST-elevation myocardial infarction. Trials. 2010;11:89.PubMedCrossRefGoogle Scholar
  20. 20.
    Safley DM, House JA, Marso SP, Grantham JA, Rutherford BD. Improvement in survival following successful percutaneous coronary intervention of coronary chronic total occlusions: variability by target vessel. JACC Cardiovasc Interv. 2008;1(3):295–302.PubMedCrossRefGoogle Scholar
  21. 21.
    Grantham JA, Marso SP, Spertus J, House J, Holmes Jr DR, Rutherford BD. Chronic total occlusion angioplasty in the United States. JACC Cardiovasc Interv. 2009;2(6):479–86.PubMedCrossRefGoogle Scholar
  22. 22.
    Christofferson RD, Lehmann KG, Martin GV, Every N, Caldwell JH, Kapadia SR. Effect of chronic total coronary occlusion on treatment strategy. Am J Cardiol. 2005;95(9):1088–91.PubMedCrossRefGoogle Scholar
  23. 23.
    Rinfret S, Joyal D, Nguyen CM, et al. Retrograde recanalization of chronic total occlusions from the transradial approach; early Canadian experience. Catheter Cardiovasc Interv. 2011;78(3):366–74.PubMedGoogle Scholar
  24. 24.
    Colombo A, Mikhail GW, Michev I, et al. Treating chronic total occlusions using subintimal tracking and reentry: the STAR technique. Catheter Cardiovasc Interv. 2005;64(4):407–11.PubMedCrossRefGoogle Scholar
  25. 25.
    Galassi AR, Tomasello SD, Costanzo L, et al. Mini-STAR as bail-out strategy for percutaneous coronary intervention of chronic total occlusion. Catheter Cardiovasc Interv. 2012;79(1):30–40.PubMedCrossRefGoogle Scholar
  26. 26.
    Badhey N, Lombardi WL, Thompson CA, Brilakis ES, Banerjee S. Use of the venture wire control catheter for subintimal coronary dissection and reentry in chronic total occlusions. J Invasive Cardiol. 2010;22(9):445–8.PubMedGoogle Scholar
  27. 27.
    Iturbe JM, Abdel-Karim AR, Raja VN, Rangan BV, Banerjee S, Brilakis ES. Use of the venture wire control catheter for the treatment of coronary artery chronic total occlusions. Catheter Cardiovasc Interv. 2010;76(7):936–41.PubMedCrossRefGoogle Scholar
  28. 28.
    • Whitlow PL, Burke MN, Lombardi WL, et al. Use of a novel crossing and re-entry system in coronary chronic total occlusions that have failed standard crossing techniques: results of the FAST-CTOs (Facilitated Antegrade Steering Technique in Chronic Total Occlusions) trial. JACC Cardiovasc Interv. 2012;5(4):393–401. This article presets the results of a multicentric pilot efficacy and safety trial (FAST-CTO) employing the CrossBoss and Stingray technology.PubMedCrossRefGoogle Scholar
  29. 29.
    Godino C, Latib A, Economou FI, Al-Lamee R, Ielasi A, Bassanelli G, Figini F, Chieffo A, Montorfano M, Colombo A, Carlino M. Coronary chronic total occlusions: Mid-term comparison of clinical outcome following the use of the guided-star technique and conventional anterograde approaches. Catheter Cardiovasc Interv. 2012;79:20–7.PubMedCrossRefGoogle Scholar
  30. 30.
    Michael TT, Papayannis AC, Banerjee S, Brilakis ES. Dissection/Re-entry Strategies in Coronary Chronic Total Occlusion Interventions. Circ Cardiovasc Interv 2012:5:729–38.Google Scholar
  31. 31.
    Rathore S, Katoh O, Matsuo H, et al. Retrograde percutaneous recanalization of chronic total occlusion of the coronary arteries: procedural outcomes and predictors of success in contemporary practice. Circ Cardiovasc Interv. 2009;2(2):124–32.PubMedCrossRefGoogle Scholar
  32. 32.
    Karmpaliotis D, Michael TT, Brilakis ES, et al. Retrograde Coronary Chronic Total Occlusion Revascularization: Procedural and In-Hospital Procedural Outcomes from a Multicenter Registry in the United States. JACC Cardiovasc Interv. In press. Google Scholar
  33. 33.
    • Brilakis ES, Grantham JA, Thompson CA, et al. The retrograde approach to coronary artery chronic total occlusions: a practical approach. Catheter Cardiovasc Interv. 2012;79(1):3–19. This article presents a step-by-step description of retrograde techniques.PubMedCrossRefGoogle Scholar
  34. 34.
    • Joyal D, Thompson CA, Grantham JA, Buller CE, Rinfret S. The retrograde technique for recanalization of chronic total occlusions: a step-by-step approach. JACC Cardiovasc Interv. 2012;5(1):1–11. This article presents a step-by-step description of retrograde techniques.PubMedCrossRefGoogle Scholar
  35. 35.
    Ozawa N. A new understanding of chronic total occlusion from a novel PCI technique that involves a retrograde approach to the right coronary artery via a septal branch and passing of the guidewire to a guiding catheter on the other side of the lesion. Catheter Cardiovasc Interv. 2006;68(6):907–13.PubMedCrossRefGoogle Scholar
  36. 36.
    Werner GS, Ferrari M, Heinke S, et al. Angiographic assessment of collateral connections in comparison with invasively determined collateral function in chronic coronary occlusions. Circulation. 2003;107(15):1972–7.PubMedCrossRefGoogle Scholar
  37. 37.
    •• Brilakis ES, Grantham JA, Rinfret S, et al. A percutaneous treatment algorithm for crossing coronary chronic total occlusions. JACC Cardiovasc Interv. 2012;5(4):367–79. This article presents a step-by-step algorithm for CTO crossing based on expert consensus and incorporating all currently available crossing strategies.PubMedCrossRefGoogle Scholar
  38. 38.
    Saeed B, Kandzari DE, Agostoni P, et al. Use of drug-eluting stents for chronic total occlusions: a systematic review and meta-analysis. Catheter Cardiovasc Interv. 2011;77(3):315–32.PubMedCrossRefGoogle Scholar
  39. 39.
    Colmenarez HJ, Escaned J, Fernandez C, et al. Efficacy and safety of drug-eluting stents in chronic total coronary occlusion recanalization: a systematic review and meta-analysis. J Am Coll Cardiol. 2010;55(17):1854–66.PubMedCrossRefGoogle Scholar
  40. 40.
    Kandzari DE, Rao SV, Moses JW, et al. Clinical and angiographic outcomes with sirolimus-eluting stents in total coronary occlusions: the ACROSS/TOSCA-4 (Approaches to Chronic Occlusions With Sirolimus-Eluting Stents/Total Occlusion Study of Coronary Arteries-4) trial. JACC Cardiovasc Interv. 2009;2:97–106.PubMedCrossRefGoogle Scholar
  41. 41.
    • Brilakis ES, Karmapaliotis D, Patel V, Banerjee S. Complications of chronic total occlusion angioplasty. Intervent Cardiol Clin. 2012;1:373–89. This article presents complications specific to CTO-PCI with detailed graphs and pictures while also providing tips and tricks to avoid and treat complications.CrossRefGoogle Scholar
  42. 42.
    Suero JA, Marso SP, Jones PG, et al. Procedural outcomes and long-term survival among patients undergoing percutaneous coronary intervention of a chronic total occlusion in native coronary arteries: a 20-year experience. J Am Coll Cardiol. 2001;38(2):409–14.PubMedCrossRefGoogle Scholar
  43. 43.
    Papayannis A, Banerjee S, Brilakis ES. Use of the crossboss catheter in coronary chronic total occlusion due to in-stent restenosis. Catheter Cardiovasc Interv. 2012;80(2):E30–36.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media New York (outside the USA)  2013

Authors and Affiliations

  • Santiago Garcia
    • 1
  • Shuaib Abdullah
    • 3
    • 4
  • Subhash Banerjee
    • 2
    • 3
  • Emmanouil S. Brilakis
    • 2
    • 3
    • 4
  1. 1.Minneapolis VA Healthcare SystemMinneapolisUSA
  2. 2.VA North Texas Healthcare SystemDallasUSA
  3. 3.University of Texas Southwestern Medical CenterDallasUSA
  4. 4.Dallas VA Medical Center (111A)DallasUSA

Personalised recommendations