Chronic total occlusions: A European global perspective

Treatment of chronic total occlusion (CTO) lesions still represents the last frontier for the interventionalist. Although the most important cause of procedural failure is the inability to cross the occlusion with the guide wire and to reach the distal true lumen end, other factors may prevent balloon crossing and final recanalisation. Moreover, the recurrence rate of restenosis and reocclusion is higher compared with other subsets of lesions. Data obtained over the past decade have shown that successful recanalisabon of CTO provides long-term outcome improvement, left ventricular ejection fraction improvement, electrical stability of myocardium and improved tolerance for future coronary events. However, because of the perceived procedural complexity of the percutaneous coronary intervention (PCI), patients with CTO are generally referred for coronary artery bypass graft (CABG) surgery or medical therapy. Recent development of PCI materials, devices, approaches and techniques have allowed expert operators to tackle with success complex cases of CTO, that in previous years would have sent patients to surgery. This has also been motivated by the long-term patency and freedom from restenosis obtained by the use of drug-eluting stents (DES). Every strategy and device has its advantages as well as its disadvantages, bearing in mind that percutaneous treatment of CTOs needs more operator skill than treatment of other non-occlusive lesions and that it requires a period of dedicated training. In order to avoid complications and to succeed in CTO recanalisation in at least 70% of cases it is extremely important to perform proper procedural planning, to understand the principles of each strategy, to be able to handle the necessary materials, to take time, to be 'zen' and be aware when to stop.