New percutaneous approaches for chronic total occlusion of coronary arteries

Successful recanalization and percutaneous revascularization of coronary arteries with chronic total occlusion (CTO) is one of the 'last frontiers' in coronary interventions. Conquering this obstacle will enable complete percutaneous revascularization in an increasing number of patients. The introduction within the last few years of enhanced guidewires combined with increasing operator experience and creative procedural techniques, such as the retrograde approach and the re-entry subintimal tracking technique (STAR), have significantly reduced the number of CTOs that should now be considered unapproachable. In addition, novel devices have been developed over recent years that may increase the success rate, as well as the safety, of the procedure. The Safe-Cross radiofrequency combines optical coherence reflectometry that warns the operator when the wire tip moves to within 1 mm of the outer vessel wall, combined with radiofrequency energy pulses to facilitate the passage. The CROSSER catheter mechanically vibrates against the face of the CTO at 20 kHz at a stroke depth of approximately 20 microm, creating a channel through the CTO. The most novel approach is the biologic one, in which proteolytic enzymes that digest the CTO cap to facilitate mechanical passage. The success rates for otherwise refractory CTOs will continue to improve with the development and validation of new imaging modalities and active energy source catheters.