The aim of this chapter will be to provide a systematic overview of the current state-of-the art in percutaneous recanalization of CTO, to enhance the understanding of this complex procedure and, consequently, promote safe and effective PCI for patients who present with this lesion subset. It should keep in mind that reopening of a CTO needs to be carefully considered in the presence of symptoms or objective evidence of viability/ischaemia in the territory of the occluded artery. In particular, the retrograde CTO PCI approach, that was first mastered by Japanese operators, has evolved rapidly, resulting in higher success rates, shortened procedural time and reduced exposure to radiation. Nowadays, specifically trained operators are able to improve the rate of CTO recanalization thanks to several new techniques and dedicated device developments. Historically, a procedural success rate of 60-70% was achieved using anterograde approach. Patients with untreated CTOs face a threefold increase in cardiac mortality or complications in case of future acute events. Perhaps for the fact that procedural success is hampered by the difficulties associated with crossing and/or dilating the occluded segment with guidewires and recanalization devices and by a high incidence of restenosis and reocclusion.ĭespite these obstacles, several studies have documented that successful PCI of CTOs leads to an improvement in anginal status, normalization of functional tests, improvement of left ventricular function and avoidance of coronary artery bypass graft surgery (CABG). However only 7-15% of CTOs were treated with percutaneous coronary intervention (PCI) ( Figure 1). This coronary lesion subset is a frequent finding in patients with coronary artery disease (CAD) as CTOs have been reported in approximately one-third of patients undergoing diagnostic coronary angiography. Chronic total occlusion (CTO) of coronary arteries is one of the most challenging PCI, usually defined as more than three-month-old obstruction of a native coronary artery.
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