Tips & tricks on PCI for chronic total occlusions


Approximately up 30-40% of patients with coronary artery disease shows at angiography at least one occluded artery, but only 7-15% of chronic total occlusion (CTO) are treated by percutaneous coronary intervention. Thus, the majority of occluded vessels are not treated by coronary angioplasty but with coronary artery by-pass graft or medical therapy. Various studies have indicated that presence of CTO is the most important factor for selecting bypass as the choice of coronary vascular revascularization.

Treatment of CTO lesions still represents the last frontier for the interventionalist. New guide wires, techniques and specific devices have led to higher procedural success rate, and nowdays recanalisation may be achieved in 70-80% in hands of expert operators. Even in this subset of lesions drug-eluting stents significantly reduced the incidence of restenosis and reocclusion, providing also to these complex procedures improved long-term patency.

Considering all these dynamic changes, and difficulties of these procedures, Dr Alfredo R Galassi, Ferrarotto Hospital, University of Catania, Italy, is lauching the comprehensive and practical handbook Percutaneous Coronary Interventions for Chronic Total Occlusions – Galassi’s Tips & Tricks.

“When I thought to this handbook my intention was to provide a meaningful and concise practical guide for the interventional cardiologist, who has good overall experience in the field of coronary angioplasty, and he is willing to improve its skilfulness in the field of revascularisation of CTO,” said Galassi.

The content underlines clinical treatment issues, operator different techniques, and practical case-based scenarios for each of different situations that an interventionalist may encounter during recanalisation of a CTO. “Thus, this handbook is meant to assist the interventionalist in the treatment of complex coronary disease such as CTO and I highly recommend it, expecting from it great success in the field of complex interventional cardiology,” added Galassi.

The first part of the handbook deals with anatomy and histopathology of CTO, and epidemiology and definition of CTO. The second part deals with clinical indication to CTO revascularisation, including patient selection based on non-invasive functional imaging, the role of collateral circulation, and predictive factors related to success of recanalisation. The third part deals with basic principles and different materials for CTO recanalisation. Different antegrade approaches, different devices and retrograde approaches are described in details with practical case-based scenarios. The fourth part describes use of stents, the percutaneous coronary intervention strategy after crossing the lesion, including treatment of long segments, bifurcations and small vessels, when to stop procedures, when to perform a second attempt. Finally, the fifth part describes procedural complications and their management, radiation and contrast media exposure, operator training and organization of CTO centres.

The foreword was written by Dr Corrado Tamburino, Ferrarotto Hospital, University of Catania.