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A New Algorithm for Crossing Chronic Total Occlusions From the Asia Pacific Chronic Total Occlusion Club
Scott A Harding1, Eugene B Wu2, Sidney Lo3
1Department of Cardiology, Wellington Hospital, Wellington, New Zealand.
Insights
A new algorithm for chronic total occlusion (CTO) percutaneous coronary intervention is proposed for global use, adapting to diverse skill sets and equipment. It refines case selection and strategy, moving beyond the hybrid algorithm for better CTO PCI outcomes.
Area of Science:
- Cardiology
- Interventional Cardiology
Background:
- The hybrid algorithm for chronic total occlusion (CTO) percutaneous coronary intervention (PCI) has seen limited adoption in the Asia Pacific region.
- A need exists for a globally applicable CTO algorithm that accommodates varying skill levels and equipment availability.
Purpose of the Study:
- To propose a new, globally applicable CTO algorithm for case selection and procedural strategy.
- To provide practical guidance for CTO PCI, incorporating new techniques and considerations.
Main Methods:
- The algorithm bases case selection on the Japan-CTO score and a new CTO algorithm.
- It evaluates proximal cap ambiguity, distal vessel quality, and interventional collaterals to determine antegrade or retrograde approach.
- Decision-making for wire escalation versus dissection re-entry strategies considers multiple factors beyond occlusion length, including vessel course ambiguity, calcification, tortuosity, and prior failures.
Main Results:
- The algorithm incorporates intravascular ultrasound-guided entry for proximal cap ambiguity and the CrossBoss catheter for in-stent restenosis.
- It includes parallel wire technique and dissection re-entry with the Stingray system for failed antegrade wire passage.
- Intravascular ultrasound-guided wiring and limited subintimal tracking/re-entry are presented as final options, with guidance on procedure termination.
Conclusions:
- This new algorithm offers a practical framework for CTO PCI, adaptable to different settings.
- It aims to enhance the adoption and effectiveness of CTO PCI procedures globally.
- The algorithm is intended to serve as a foundation for future CTO PCI proctoring and training programs.
Abstract:
Although the hybrid chronic total occlusion (CTO) algorithm had many excellent recommendations, there has been infrequent adoption in the Asia Pacific region. The Asia Pacific CTO club propose an algorithm for case selection based on the Japan-CTO score and a new CTO algorithm, which is applicable globally. This algorithm allows for differing skill sets and equipment availability and contains practical teaching for CTO percutaneous coronary intervention. Similar to the hybrid algorithm there are 3 main questions that determine whether the primary approach is antegrade or retrograde: 1) is there proximal cap ambiguity; 2) is the distal vessel of poor quality; and 3) are there interventional collaterals present. In contrast to the hybrid algorithm occlusion length alone does not determine the choice of either a wire escalation strategy or a dissection re-entry strategy. Rather a combination of factors including ambiguity of the vessel course, severe calcification, tortuosity, length, and previous failure are used to determine this. The role of intravascular ultrasound-guided entry to overcome proximal cap ambiguity and the CrossBoss catheter in occlusive in-stent restenosis are highlighted in the algorithm. Both the parallel wire technique and dissection re-entry with the Stingray system have been included as options when the initial antegrade wire passage fails. Intravascular ultrasound-guided wiring along with limited subintimal tracking and re-entry are included as final options in the algorithm. Finally, the algorithm incorporates guidance on when to stop the procedure. It is hoped that this algorithm will serve as the basis for future CTO percutaneous coronary intervention proctoring and training.