“Putting it all together”: A global approach to chronic total occlusion revascularization

Percutaneous coronary intervention (PCI) of chronic total occlusion (CTO) represents a common and significant management dilemma for the interventionist. The optimal approach to CTO PCI continues to evolve. Currently, success rate of CTO PCI seems markedly improved due to new techniques and dedicated device developments. Retrograde recanalization devised by Japanese proved to be one of the most significant amendments of the technique. However, there are barriers that could limit widespread dissemination of Japanese techniques. Long case duration, financial constraints, radiation overdose and contrast overload in protracted cases may be concerns outside Japan. Moreover, various CTO crossing techniques such as antegrade wire escalation, antegrade disection/re-entry, and retrograde enjoy relative merits and priority in isolated cases. Putting it all together or global approach involves a standard, simplified process to target CTO PCI dictated by anatomy, harmonizing antegrade and retrograde techniques, harmonizing lesion wire or device-based crossing with dissection and re-entry methods.