Masahisa Yamane, Kenya Nasu, Masaaki Okutsu, Makoto Sekiguchi
Chronic total occlusion
Updated on August 26, 2021
Chronic total occlusion
The hybrid approach to CTO intervention
Updated on May 13, 2021 | 14 minutes reading
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Summary
The “hybrid” algorithm for chronic total occlusion (CTO) percutaneous coronary intervention (PCI) was developed to guide selection of the optimal CTO crossing strategy in a stepwise fashion. Dual injection should be performed in nearly all CTO PCI procedures. Four angiographic lesion characteristics are assessed (1) proximal cap ambiguity, (2) quality of the distal vessel, (3) lesion length and (4) presence of collateral vessels suitable for the retrograde approach. Wire escalation is favored for <20 mm long lesions, whereas dissection and re-entry is favored for >20 mm long lesions. The antegrade approach is favored when the proximal cap is clear, and the retrograde approach is favored for lesions with an ambiguous proximal cap and/or diffusely diseased distal vessel, provided that appropriate collateral vessels are present. Early change of crossing strategy is recommended if the initially selected crossing strategy fails.
Rationale for the hybrid algorithm
Several techniques have been developed for crossing coronary chronic total occlusions (CTOs). These techniques can be classified according to the direction of wire advancement (antegrade and retrograde) and use of the subintimal space (intraplaque wiring vs. dissection and reentry) (Figure 1) 1
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