Guiding Principles for Chronic Total Occlusion Percutaneous Coronary Intervention

Emmanouil S. Brilakis, Kambis Mashayekhi, Etsuo Tsuchikane, Nidal Abi Rafeh, Khaldoon Alaswad, Mario Araya, Alexandre Avran, Lorenzo Azzalini, Avtandil M. Babunashvili, Baktash Bayani, Ravinay Bhindi, Nicolas Boudou, Marouane Boukhris, Nenad Božinović, Leszek Bryniarski, Alexander Bufe, Christopher E. Buller, M. Nicholas Burke, Heinz Joachim Büttner, Pedro CardosoMauro Carlino, Evald H. Christiansen, Antonio Colombo, Kevin Croce, Felix Damas de Los Santos, Tony De Martini, Joseph Dens, Carlo Di Mario, Kefei Dou, Mohaned Egred, Ahmed M. ElGuindy, Javier Escaned, Sergey Furkalo, Andrea Gagnor, Alfredo R. Galassi, Roberto Garbo, Junbo Ge, Pravin Kumar Goel, Omer Goktekin, Luca Grancini, J. Aaron Grantham, Colm Hanratty, Stefan Harb, Scott A. Harding, Jose P.S. Henriques, Jonathan M. Hill, Farouc A. Jaffer, Yangsoo Jang, Risto Jussila, Artis Kalnins, Arun Kalyanasundaram, David E. Kandzari, Hsien Li Kao, Dimitri Karmpaliotis, Hussien Heshmat Kassem, Paul Knaapen, Ran Kornowski, Oleg Krestyaninov, A. V.Ganesh Kumar, Peep Laanmets, Pablo Lamelas, Seung Whan Lee, Thierry Lefevre, Yue Li, Soo Teik Lim, Sidney Lo, William Lombardi, Margaret McEntegart, Muhammad Munawar, José Andrés Navarro Lecaro, Hung M. Ngo, William Nicholson, Göran K. Olivecrona, Lucio Padilla, Marin Postu, Alexandre Quadros, Franklin Hanna Quesada, Vithala Surya Prakasa Rao, Nicolaus Reifart, Meruzhan Saghatelyan, Ricardo Santiago, George Sianos, Elliot Smith, James C Spratt, Gregg W. Stone, Julian W. Strange, Khalid Tammam, Imre Ungi, Minh Vo, Vu Hoang Vu, Simon Walsh, Gerald S. Werner, Jason R. Wollmuth, Eugene B. Wu, R. Michael Wyman, Bo Xu, Masahisa Yamane, Luiz F. Ybarra, Robert W. Yeh, Qi Zhang, Stephane Rinfret

Research output: Contribution to journalArticle

6 Citations (Scopus)

Abstract

Outcomes of chronic total occlusion (CTO) percutaneous coronary intervention (PCI) have improved because of advancements in equipment and techniques. With global collaboration and knowledge sharing, we have identified 7 common principles that are widely accepted as best practices for CTO-PCI.  1. Ischemic symptom improvement is the primary indication for CTO-PCI.  2. Dual coronary angiography and in-depth and structured review of the angiogram (and, if available, coronary computed tomography angiography) are key for planning and safely performing CTO-PCI.  3. Use of a microcatheter is essential for optimal guidewire manipulation and exchanges.  4. Antegrade wiring, antegrade dissection and reentry, and the retrograde approach are all complementary and necessary crossing strategies. Antegrade wiring is the most common initial technique, whereas retrograde and antegrade dissection and reentry are often required for more complex CTOs.  5. If the initially selected crossing strategy fails, efficient change to an alternative crossing technique increases the likelihood of eventual PCI success, shortens procedure time, and lowers radiation and contrast use.  6. Specific CTO-PCI expertise and volume and the availability of specialized equipment will increase the likelihood of crossing success and facilitate prevention and management of complications, such as perforation.  7. Meticulous attention to lesion preparation and stenting technique, often requiring intracoronary imaging, is required to ensure optimum stent expansion and minimize the risk of short- and long-term adverse events. These principles have been widely adopted by experienced CTO-PCI operators and centers currently achieving high success and acceptable complication rates. Outcomes are less optimal at less experienced centers, highlighting the need for broader adoption of the aforementioned 7 guiding principles along with the development of additional simple and safe CTO crossing and revascularization strategies through ongoing research, education, and training.

Original languageEnglish (US)
Pages (from-to)420-433
Number of pages14
JournalCirculation
Volume140
Issue number5
DOIs
StatePublished - Jul 30 2019
Externally publishedYes

Fingerprint

Percutaneous Coronary Intervention
Dissection
Equipment and Supplies
Coronary Angiography
Practice Guidelines
Stents
Angiography
Radiation
Education
Research

Keywords

  • coronary occlusion
  • methods
  • outcome
  • percutaneous coronary intervention
  • treatment

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine
  • Physiology (medical)

Cite this

Brilakis, E. S., Mashayekhi, K., Tsuchikane, E., Abi Rafeh, N., Alaswad, K., Araya, M., ... Rinfret, S. (2019). Guiding Principles for Chronic Total Occlusion Percutaneous Coronary Intervention. Circulation, 140(5), 420-433. https://doi.org/10.1161/CIRCULATIONAHA.119.039797

Guiding Principles for Chronic Total Occlusion Percutaneous Coronary Intervention. / Brilakis, Emmanouil S.; Mashayekhi, Kambis; Tsuchikane, Etsuo; Abi Rafeh, Nidal; Alaswad, Khaldoon; Araya, Mario; Avran, Alexandre; Azzalini, Lorenzo; Babunashvili, Avtandil M.; Bayani, Baktash; Bhindi, Ravinay; Boudou, Nicolas; Boukhris, Marouane; Božinović, Nenad; Bryniarski, Leszek; Bufe, Alexander; Buller, Christopher E.; Burke, M. Nicholas; Büttner, Heinz Joachim; Cardoso, Pedro; Carlino, Mauro; Christiansen, Evald H.; Colombo, Antonio; Croce, Kevin; Damas de Los Santos, Felix; De Martini, Tony; Dens, Joseph; Di Mario, Carlo; Dou, Kefei; Egred, Mohaned; ElGuindy, Ahmed M.; Escaned, Javier; Furkalo, Sergey; Gagnor, Andrea; Galassi, Alfredo R.; Garbo, Roberto; Ge, Junbo; Goel, Pravin Kumar; Goktekin, Omer; Grancini, Luca; Grantham, J. Aaron; Hanratty, Colm; Harb, Stefan; Harding, Scott A.; Henriques, Jose P.S.; Hill, Jonathan M.; Jaffer, Farouc A.; Jang, Yangsoo; Jussila, Risto; Kalnins, Artis; Kalyanasundaram, Arun; Kandzari, David E.; Kao, Hsien Li; Karmpaliotis, Dimitri; Kassem, Hussien Heshmat; Knaapen, Paul; Kornowski, Ran; Krestyaninov, Oleg; Kumar, A. V.Ganesh; Laanmets, Peep; Lamelas, Pablo; Lee, Seung Whan; Lefevre, Thierry; Li, Yue; Lim, Soo Teik; Lo, Sidney; Lombardi, William; McEntegart, Margaret; Munawar, Muhammad; Navarro Lecaro, José Andrés; Ngo, Hung M.; Nicholson, William; Olivecrona, Göran K.; Padilla, Lucio; Postu, Marin; Quadros, Alexandre; Quesada, Franklin Hanna; Prakasa Rao, Vithala Surya; Reifart, Nicolaus; Saghatelyan, Meruzhan; Santiago, Ricardo; Sianos, George; Smith, Elliot; C Spratt, James; Stone, Gregg W.; Strange, Julian W.; Tammam, Khalid; Ungi, Imre; Vo, Minh; Vu, Vu Hoang; Walsh, Simon; Werner, Gerald S.; Wollmuth, Jason R.; Wu, Eugene B.; Wyman, R. Michael; Xu, Bo; Yamane, Masahisa; Ybarra, Luiz F.; Yeh, Robert W.; Zhang, Qi; Rinfret, Stephane.

In: Circulation, Vol. 140, No. 5, 30.07.2019, p. 420-433.

Research output: Contribution to journalArticle

Brilakis, ES, Mashayekhi, K, Tsuchikane, E, Abi Rafeh, N, Alaswad, K, Araya, M, Avran, A, Azzalini, L, Babunashvili, AM, Bayani, B, Bhindi, R, Boudou, N, Boukhris, M, Božinović, N, Bryniarski, L, Bufe, A, Buller, CE, Burke, MN, Büttner, HJ, Cardoso, P, Carlino, M, Christiansen, EH, Colombo, A, Croce, K, Damas de Los Santos, F, De Martini, T, Dens, J, Di Mario, C, Dou, K, Egred, M, ElGuindy, AM, Escaned, J, Furkalo, S, Gagnor, A, Galassi, AR, Garbo, R, Ge, J, Goel, PK, Goktekin, O, Grancini, L, Grantham, JA, Hanratty, C, Harb, S, Harding, SA, Henriques, JPS, Hill, JM, Jaffer, FA, Jang, Y, Jussila, R, Kalnins, A, Kalyanasundaram, A, Kandzari, DE, Kao, HL, Karmpaliotis, D, Kassem, HH, Knaapen, P, Kornowski, R, Krestyaninov, O, Kumar, AVG, Laanmets, P, Lamelas, P, Lee, SW, Lefevre, T, Li, Y, Lim, ST, Lo, S, Lombardi, W, McEntegart, M, Munawar, M, Navarro Lecaro, JA, Ngo, HM, Nicholson, W, Olivecrona, GK, Padilla, L, Postu, M, Quadros, A, Quesada, FH, Prakasa Rao, VS, Reifart, N, Saghatelyan, M, Santiago, R, Sianos, G, Smith, E, C Spratt, J, Stone, GW, Strange, JW, Tammam, K, Ungi, I, Vo, M, Vu, VH, Walsh, S, Werner, GS, Wollmuth, JR, Wu, EB, Wyman, RM, Xu, B, Yamane, M, Ybarra, LF, Yeh, RW, Zhang, Q & Rinfret, S 2019, 'Guiding Principles for Chronic Total Occlusion Percutaneous Coronary Intervention', Circulation, vol. 140, no. 5, pp. 420-433. https://doi.org/10.1161/CIRCULATIONAHA.119.039797
Brilakis, Emmanouil S. ; Mashayekhi, Kambis ; Tsuchikane, Etsuo ; Abi Rafeh, Nidal ; Alaswad, Khaldoon ; Araya, Mario ; Avran, Alexandre ; Azzalini, Lorenzo ; Babunashvili, Avtandil M. ; Bayani, Baktash ; Bhindi, Ravinay ; Boudou, Nicolas ; Boukhris, Marouane ; Božinović, Nenad ; Bryniarski, Leszek ; Bufe, Alexander ; Buller, Christopher E. ; Burke, M. Nicholas ; Büttner, Heinz Joachim ; Cardoso, Pedro ; Carlino, Mauro ; Christiansen, Evald H. ; Colombo, Antonio ; Croce, Kevin ; Damas de Los Santos, Felix ; De Martini, Tony ; Dens, Joseph ; Di Mario, Carlo ; Dou, Kefei ; Egred, Mohaned ; ElGuindy, Ahmed M. ; Escaned, Javier ; Furkalo, Sergey ; Gagnor, Andrea ; Galassi, Alfredo R. ; Garbo, Roberto ; Ge, Junbo ; Goel, Pravin Kumar ; Goktekin, Omer ; Grancini, Luca ; Grantham, J. Aaron ; Hanratty, Colm ; Harb, Stefan ; Harding, Scott A. ; Henriques, Jose P.S. ; Hill, Jonathan M. ; Jaffer, Farouc A. ; Jang, Yangsoo ; Jussila, Risto ; Kalnins, Artis ; Kalyanasundaram, Arun ; Kandzari, David E. ; Kao, Hsien Li ; Karmpaliotis, Dimitri ; Kassem, Hussien Heshmat ; Knaapen, Paul ; Kornowski, Ran ; Krestyaninov, Oleg ; Kumar, A. V.Ganesh ; Laanmets, Peep ; Lamelas, Pablo ; Lee, Seung Whan ; Lefevre, Thierry ; Li, Yue ; Lim, Soo Teik ; Lo, Sidney ; Lombardi, William ; McEntegart, Margaret ; Munawar, Muhammad ; Navarro Lecaro, José Andrés ; Ngo, Hung M. ; Nicholson, William ; Olivecrona, Göran K. ; Padilla, Lucio ; Postu, Marin ; Quadros, Alexandre ; Quesada, Franklin Hanna ; Prakasa Rao, Vithala Surya ; Reifart, Nicolaus ; Saghatelyan, Meruzhan ; Santiago, Ricardo ; Sianos, George ; Smith, Elliot ; C Spratt, James ; Stone, Gregg W. ; Strange, Julian W. ; Tammam, Khalid ; Ungi, Imre ; Vo, Minh ; Vu, Vu Hoang ; Walsh, Simon ; Werner, Gerald S. ; Wollmuth, Jason R. ; Wu, Eugene B. ; Wyman, R. Michael ; Xu, Bo ; Yamane, Masahisa ; Ybarra, Luiz F. ; Yeh, Robert W. ; Zhang, Qi ; Rinfret, Stephane. / Guiding Principles for Chronic Total Occlusion Percutaneous Coronary Intervention. In: Circulation. 2019 ; Vol. 140, No. 5. pp. 420-433.
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abstract = "Outcomes of chronic total occlusion (CTO) percutaneous coronary intervention (PCI) have improved because of advancements in equipment and techniques. With global collaboration and knowledge sharing, we have identified 7 common principles that are widely accepted as best practices for CTO-PCI.  1. Ischemic symptom improvement is the primary indication for CTO-PCI.  2. Dual coronary angiography and in-depth and structured review of the angiogram (and, if available, coronary computed tomography angiography) are key for planning and safely performing CTO-PCI.  3. Use of a microcatheter is essential for optimal guidewire manipulation and exchanges.  4. Antegrade wiring, antegrade dissection and reentry, and the retrograde approach are all complementary and necessary crossing strategies. Antegrade wiring is the most common initial technique, whereas retrograde and antegrade dissection and reentry are often required for more complex CTOs.  5. If the initially selected crossing strategy fails, efficient change to an alternative crossing technique increases the likelihood of eventual PCI success, shortens procedure time, and lowers radiation and contrast use.  6. Specific CTO-PCI expertise and volume and the availability of specialized equipment will increase the likelihood of crossing success and facilitate prevention and management of complications, such as perforation.  7. Meticulous attention to lesion preparation and stenting technique, often requiring intracoronary imaging, is required to ensure optimum stent expansion and minimize the risk of short- and long-term adverse events. These principles have been widely adopted by experienced CTO-PCI operators and centers currently achieving high success and acceptable complication rates. Outcomes are less optimal at less experienced centers, highlighting the need for broader adoption of the aforementioned 7 guiding principles along with the development of additional simple and safe CTO crossing and revascularization strategies through ongoing research, education, and training.",
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TY - JOUR

T1 - Guiding Principles for Chronic Total Occlusion Percutaneous Coronary Intervention

AU - Brilakis, Emmanouil S.

AU - Mashayekhi, Kambis

AU - Tsuchikane, Etsuo

AU - Abi Rafeh, Nidal

AU - Alaswad, Khaldoon

AU - Araya, Mario

AU - Avran, Alexandre

AU - Azzalini, Lorenzo

AU - Babunashvili, Avtandil M.

AU - Bayani, Baktash

AU - Bhindi, Ravinay

AU - Boudou, Nicolas

AU - Boukhris, Marouane

AU - Božinović, Nenad

AU - Bryniarski, Leszek

AU - Bufe, Alexander

AU - Buller, Christopher E.

AU - Burke, M. Nicholas

AU - Büttner, Heinz Joachim

AU - Cardoso, Pedro

AU - Carlino, Mauro

AU - Christiansen, Evald H.

AU - Colombo, Antonio

AU - Croce, Kevin

AU - Damas de Los Santos, Felix

AU - De Martini, Tony

AU - Dens, Joseph

AU - Di Mario, Carlo

AU - Dou, Kefei

AU - Egred, Mohaned

AU - ElGuindy, Ahmed M.

AU - Escaned, Javier

AU - Furkalo, Sergey

AU - Gagnor, Andrea

AU - Galassi, Alfredo R.

AU - Garbo, Roberto

AU - Ge, Junbo

AU - Goel, Pravin Kumar

AU - Goktekin, Omer

AU - Grancini, Luca

AU - Grantham, J. Aaron

AU - Hanratty, Colm

AU - Harb, Stefan

AU - Harding, Scott A.

AU - Henriques, Jose P.S.

AU - Hill, Jonathan M.

AU - Jaffer, Farouc A.

AU - Jang, Yangsoo

AU - Jussila, Risto

AU - Kalnins, Artis

AU - Kalyanasundaram, Arun

AU - Kandzari, David E.

AU - Kao, Hsien Li

AU - Karmpaliotis, Dimitri

AU - Kassem, Hussien Heshmat

AU - Knaapen, Paul

AU - Kornowski, Ran

AU - Krestyaninov, Oleg

AU - Kumar, A. V.Ganesh

AU - Laanmets, Peep

AU - Lamelas, Pablo

AU - Lee, Seung Whan

AU - Lefevre, Thierry

AU - Li, Yue

AU - Lim, Soo Teik

AU - Lo, Sidney

AU - Lombardi, William

AU - McEntegart, Margaret

AU - Munawar, Muhammad

AU - Navarro Lecaro, José Andrés

AU - Ngo, Hung M.

AU - Nicholson, William

AU - Olivecrona, Göran K.

AU - Padilla, Lucio

AU - Postu, Marin

AU - Quadros, Alexandre

AU - Quesada, Franklin Hanna

AU - Prakasa Rao, Vithala Surya

AU - Reifart, Nicolaus

AU - Saghatelyan, Meruzhan

AU - Santiago, Ricardo

AU - Sianos, George

AU - Smith, Elliot

AU - C Spratt, James

AU - Stone, Gregg W.

AU - Strange, Julian W.

AU - Tammam, Khalid

AU - Ungi, Imre

AU - Vo, Minh

AU - Vu, Vu Hoang

AU - Walsh, Simon

AU - Werner, Gerald S.

AU - Wollmuth, Jason R.

AU - Wu, Eugene B.

AU - Wyman, R. Michael

AU - Xu, Bo

AU - Yamane, Masahisa

AU - Ybarra, Luiz F.

AU - Yeh, Robert W.

AU - Zhang, Qi

AU - Rinfret, Stephane

PY - 2019/7/30

Y1 - 2019/7/30

N2 - Outcomes of chronic total occlusion (CTO) percutaneous coronary intervention (PCI) have improved because of advancements in equipment and techniques. With global collaboration and knowledge sharing, we have identified 7 common principles that are widely accepted as best practices for CTO-PCI.  1. Ischemic symptom improvement is the primary indication for CTO-PCI.  2. Dual coronary angiography and in-depth and structured review of the angiogram (and, if available, coronary computed tomography angiography) are key for planning and safely performing CTO-PCI.  3. Use of a microcatheter is essential for optimal guidewire manipulation and exchanges.  4. Antegrade wiring, antegrade dissection and reentry, and the retrograde approach are all complementary and necessary crossing strategies. Antegrade wiring is the most common initial technique, whereas retrograde and antegrade dissection and reentry are often required for more complex CTOs.  5. If the initially selected crossing strategy fails, efficient change to an alternative crossing technique increases the likelihood of eventual PCI success, shortens procedure time, and lowers radiation and contrast use.  6. Specific CTO-PCI expertise and volume and the availability of specialized equipment will increase the likelihood of crossing success and facilitate prevention and management of complications, such as perforation.  7. Meticulous attention to lesion preparation and stenting technique, often requiring intracoronary imaging, is required to ensure optimum stent expansion and minimize the risk of short- and long-term adverse events. These principles have been widely adopted by experienced CTO-PCI operators and centers currently achieving high success and acceptable complication rates. Outcomes are less optimal at less experienced centers, highlighting the need for broader adoption of the aforementioned 7 guiding principles along with the development of additional simple and safe CTO crossing and revascularization strategies through ongoing research, education, and training.

AB - Outcomes of chronic total occlusion (CTO) percutaneous coronary intervention (PCI) have improved because of advancements in equipment and techniques. With global collaboration and knowledge sharing, we have identified 7 common principles that are widely accepted as best practices for CTO-PCI.  1. Ischemic symptom improvement is the primary indication for CTO-PCI.  2. Dual coronary angiography and in-depth and structured review of the angiogram (and, if available, coronary computed tomography angiography) are key for planning and safely performing CTO-PCI.  3. Use of a microcatheter is essential for optimal guidewire manipulation and exchanges.  4. Antegrade wiring, antegrade dissection and reentry, and the retrograde approach are all complementary and necessary crossing strategies. Antegrade wiring is the most common initial technique, whereas retrograde and antegrade dissection and reentry are often required for more complex CTOs.  5. If the initially selected crossing strategy fails, efficient change to an alternative crossing technique increases the likelihood of eventual PCI success, shortens procedure time, and lowers radiation and contrast use.  6. Specific CTO-PCI expertise and volume and the availability of specialized equipment will increase the likelihood of crossing success and facilitate prevention and management of complications, such as perforation.  7. Meticulous attention to lesion preparation and stenting technique, often requiring intracoronary imaging, is required to ensure optimum stent expansion and minimize the risk of short- and long-term adverse events. These principles have been widely adopted by experienced CTO-PCI operators and centers currently achieving high success and acceptable complication rates. Outcomes are less optimal at less experienced centers, highlighting the need for broader adoption of the aforementioned 7 guiding principles along with the development of additional simple and safe CTO crossing and revascularization strategies through ongoing research, education, and training.

KW - coronary occlusion

KW - methods

KW - outcome

KW - percutaneous coronary intervention

KW - treatment

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UR - http://www.scopus.com/inward/citedby.url?scp=85064845892&partnerID=8YFLogxK

U2 - 10.1161/CIRCULATIONAHA.119.039797

DO - 10.1161/CIRCULATIONAHA.119.039797

M3 - Article

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AN - SCOPUS:85064845892

VL - 140

SP - 420

EP - 433

JO - Circulation

JF - Circulation

SN - 0009-7322

IS - 5

ER -