New Frontiers in Antegrade Wiring From the Asia Pacific Chronic Total Occlusion Club

Antegrade wiring (AW) is the prevailing chronic total occlusion (CTO) crossing technique. For proximal cap ambiguity, the Global CTO consensus group uses the "anatomy dictates strategy" method: 1) intravascular ultrasound; 2) move the cap; or 3) retrograde. For CTO body crossing, anatomy dictates 4 strategies: 1) CTOs with tapered stump-loose tissue tracking; 2) CTOs with clear intimal path-intentional intimal tracking with 3-dimensional (3D) wiring; 3) CTOs without a clear intimal path-intentional intimal tracking with intermediate penetration wire; and 4) the "long plus CTOs"-intentional subintimal wiring. The new angiographic 3D antegrade puncture technique from the APCTO (Asia Pacific Chronic Total Occlusion) Club is presented for distal cap puncture. angiographic 3D antegrade puncture technique can be used as a 3D wiring technique as well as an antegrade dissection and re-entry technique. Based on these new frontiers, we have updated our APCTO algorithm in this paper. This update can form a basis for research and training.