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Coronary chronic total occlusions (CTOs) are defined as coronary lesions with Thrombolysis in Myocardial Infarction (TIMI) grade 0 flow of at least 3 months in duration. Coronary CTOs are common, being encountered in approximately 1 in 3 patients who are found to have coronary artery disease during coronary angiography (range, 18%-52%; Table 12-1).1-5 Numerous patients with CTOs have complex coronary artery disease and are referred for coronary artery bypass graft surgery (CABG), but many are referred for percutaneous coronary intervention (PCI).

Table 12-1Prevalence of Coronary Chronic Total Occlusions (CTOs)


The main indication for CTO PCI is to improve symptoms6,7 and decrease the need for antianginal medications. Successful CTO PCI can improve exercise capacity,8 decrease the need for CABG, improve left ventricular systolic function,9-18 and decrease the risk for arrhythmias.19 Several studies and meta-analyses have demonstrated that patients who underwent successful CTO PCI had lower mortality compared with patients in whom CTO PCI attempts were unsuccessful (Figure 12-1).7,20-22 This could at least in part be related to achievement of more complete revascularization,23,24 as CTOs are the most common reason for not achieving complete coronary revascularization. Despite these potential benefits, CTO PCI is infrequently attempted due to concerns about procedural success and complications, as well as limited data from randomized controlled trials.

Figure 12-1

Forest plot for long-term all-cause mortality with successful versus failed CTO PCI. (Used with permission from Christakopoulos GE, Christopoulos G, Carlino M, et al. Meta-analysis of clinical outcomes of patients who underwent percutaneous coronary interventions for chronic total occlusions. Am J Cardiol. 2015;115:1367-1375.)


CTO recanalization can be challenging and requires careful planning. CTO PCI should, in most cases, not be performed at the same time as diagnostic angiography for a number of reasons: (1) to reduce the radiation and contrast dose; (2) to allow discussion with the patient and the family about the risks, goals, benefits, and alternatives of the procedure; and (3) to allow detailed review of the coronary angiogram.

Figure 12-2 outlines some essential components of planning for CTO PCI. Although high success rates can be achieved using radial access,25 CTO PCI is best performed using femoral access with bilateral 8-Fr, 45-cm-long sheaths. ...

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