Crossing CTOs-the tips, tricks, and specialist kit that can mean the difference between success and failure

Percutaneous coronary intervention (PCI) for chronic total occlusions (CTO) remains one of the major challenges in interventional cardiology. The appropriate use of the rapidly increasing range of tools available to interventional cardiologists is bringing more and more CTOs into the 'treatable' category. The bar has now been raised to 80% success rates by some expert operators around the world, which, in our view, cannot be achieved without a thorough understanding of technique and technical know-how. CTO procedures are increasingly becoming a sub-specialist field within interventional cardiology and we would encourage centers to consider appointing 'super-specialists' who are able to concentrate experience and expertise in this area. In this paper we detail the principal characteristics of the over the wire balloons, microcatheters and guidewires at present available, the most popular and recent of which are listed in Table 1 and 2. The knowledge and the specific choice of these materials and the criteria for selection of your guidewire or microcatheter can mean the difference between success and failure. Moreover, we discuss on the most important and groundbreaking techniques to approach a CTO. Finally, considering the greater risk of coronary perforation related to a CTO procedure compared to routine PCI, we describe which are best strategy and devices for treating coronary perforations and other major complications.