This document provides guidance on evaluating the feasibility of percutaneous coronary intervention (PCI) for a chronic total occlusion (CTO). Key factors to consider include: the patient's tolerance for a long procedure, contrast load, and radiation exposure; the CTO's proximal cap ambiguity, length, distal landing zone, and presence of interventional collaterals; and ensuring good quality angiography. With adequate planning and use of appropriate CTO techniques, feasibility is nearly always present for symptomatic patients. Success rates of CTO-PCI are reported to be 94% when using a planned approach.

1. How to evaluate the feasibility of
a CTO PCI
Evald Høj Christiansen
Aarhus University Hospital
Denmark
PCI department
Aarhus University Hospital, Skejby ● Denmark evald.christiansen@dadlnet.dk

2. Feasibility
• The patient
• The anatomy
• The operator
• The equipment

3. The Patient
• Dual access possible?
• Kidney function: GFRx5 = maximum total contrast
• Tolerate a long procedure?
• Tolerate ACT > 300 sec
• BMI: < 6Gy < 12Gy = stop

4. Important anatomical considerations
• The proximal CTO cap
• CTO length
• Side branch at a distal cap
• Distal landing zone
• Interventional collaterals

6. Good quality coronary angiogram
• Wide field of view
• Long runs
• Avoidance of panning
• Dual injections

7. Typical angiogram

8. The proximal cap
• Ambiguous?
= Lack of clarity of where the occlusion start
Due to presence of side branches or bridging collaterals
• Eliminate with
– IVUS (8F)
– CT
– Coronary angiogram before CTO
– Wire behavior: “knuckling” a polymer wire
– Placement of a retrograde wire
• Calcified: can a wire pass? Can a device pass?
• Ostial? Proximal? Anchor options?
• Place for “scratch and go”?

9. Proximal occluded RCA

10. Corsair and retrograde wire eliminated
the proximal ambiguity

11. Probable location of prox. cap

12. Hockey Stick guiding

13. Reverse CART

14. Final

15. Distal landing zone
• Free of disease?
• Heavily diseased?
• Calcium?
• Birfurcation?
 Odds for successful reentry stick?
 Odds for loosing a side branch?

16. 1 No proximal
cap ambiguity
2 length >> 20
mm
3 Landing zone
at bifurcation
4 No
interventional
collaterals
What to do?
A CrossBoss case 2011

20. No symptoms
We decided to do
nothing
Follow-up to do the bifurcation

21. RCA CTO collateral patterns

22. CX CTO collateral patterns

23. LAD CTO collateral patterns

24. Classification of collaterals
• Septal vs Epicardial
• CC0, CC1, CC2: channel size
• Dominance or not (tolerability)
• Straight - tortuous (telephone cord, corkscrew)
• Bifurcations – trifurcations (tip injections, projection)
• Visible – invisible connection?
• “Interventional” (possible – impossible)
• Angle in (donor vessel exit) - angle out (exit angle)
• Collateral exit -> distal cap: short - long

31. Exit -> distal cap: short

32. After Balloon

33. Final

34. Plan A? Plan B?

39. Conclusions
In patients with an appropriate indication for
opening a CTO (symptoms, ischemia, viability)
“feasibility” is (nearly) always present. It is a
question of adequate planning and mastering
the CTO techniques
• Bilateral injection
• Retrograde
• Antegrade: ADR or parallel wires
• Success: 1-0,43 = 94% (Plan A, B, C = 60%)