Guiding Principles for Chronic Total Occlusion Percutaneous Coronary Intervention: A Global Expert Consensus Document

Emmanouil S. Brilakis, Kambis Mashayekhi, Etsuo Tsuchikane, Nidal Abi Rafeh, Khaldoon Alaswad, Mario Araya, Alexandre Avran, Lorenzo Azzalini, Avtandil M. Babunashvili, Baktash Bayani, Ravinay Bhindi, Nicolas Boudou, Marouane Boukhris, Nenad Božinović, Leszek Bryniarski, Alexander Bufe, Christopher E. Buller, M. Nicholas Burke, Heinz Joachim Büttner, Pedro CardosoMauro Carlino, Evald H. Christiansen, Antonio Colombo, Kevin Croce, Felix Damas De Los Santos, Tony De Martini, Joseph Dens, Carlo DI Mario, Kefei Dou, Mohaned Egred, Ahmed M. Elguindy, Javier Escaned, Sergey Furkalo, Andrea Gagnor, Alfredo R. Galassi, Roberto Garbo, Junbo Ge, Pravin Kumar Goel, Omer Goktekin, Luca Grancini, J. Aaron Grantham, Colm Hanratty, Stefan Harb, Scott A. Harding, Jose P.S. Henriques, Jonathan M. Hill, Farouc A. Jaffer, Yangsoo Jang, Risto Jussila, Artis Kalnins, Arun Kalyanasundaram, David E. Kandzari, Hsien Li Kao, DImitri Karmpaliotis, Hussien Heshmat Kassem, Paul Knaapen, Ran Kornowski, Oleg Krestyaninov, A. V.Ganesh Kumar, Peep Laanmets, Pablo Lamelas, Seung Whan Lee, Thierry Lefevre, Yue Li, Soo Teik Lim, Sidney Lo, William Lombardi, Margaret McEntegart, Muhammad Munawar, José Andrés Navarro Lecaro, Hung M. Ngo, William Nicholson, Göran K. Olivecrona, Lucio Padilla, Marin Postu, Alexandre Quadros, Franklin Hanna Quesada, Vithala Surya Prakasa Rao, Nicolaus Reifart, Meruzhan Saghatelyan, Ricardo Santiago, George Sianos, Elliot Smith, James C. Spratt, Gregg W. Stone, Julian W. Strange, Khalid Tammam, Imre Ungi, Minh Vo, Vu Hoang Vu, Simon Walsh, Gerald S. Werner, Jason R. Wollmuth, Eugene B. Wu, R. Michael Wyman, Bo Xu, Masahisa Yamane, Luiz F. Ybarra, Robert W. Yeh, Qi Zhang, Stephane Rinfret

Research output: Contribution to journalReview articlepeer-review

186 Citations (Scopus)


Outcomes of chronic total occlusion (CTO) percutaneous coronary intervention (PCI) have improved because of advancements in equipment and techniques. With global collaboration and knowledge sharing, we have identified 7 common principles that are widely accepted as best practices for CTO-PCI. 1. Ischemic symptom improvement is the primary indication for CTO-PCI. 2. Dual coronary angiography and in-depth and structured review of the angiogram (and, if available, coronary computed tomography angiography) are key for planning and safely performing CTO-PCI. 3. Use of a microcatheter is essential for optimal guidewire manipulation and exchanges. 4. Antegrade wiring, antegrade dissection and reentry, and the retrograde approach are all complementary and necessary crossing strategies. Antegrade wiring is the most common initial technique, whereas retrograde and antegrade dissection and reentry are often required for more complex CTOs. 5. If the initially selected crossing strategy fails, efficient change to an alternative crossing technique increases the likelihood of eventual PCI success, shortens procedure time, and lowers radiation and contrast use. 6. Specific CTO-PCI expertise and volume and the availability of specialized equipment will increase the likelihood of crossing success and facilitate prevention and management of complications, such as perforation. 7. Meticulous attention to lesion preparation and stenting technique, often requiring intracoronary imaging, is required to ensure optimum stent expansion and minimize the risk of short- and long-term adverse events. These principles have been widely adopted by experienced CTO-PCI operators and centers currently achieving high success and acceptable complication rates. Outcomes are less optimal at less experienced centers, highlighting the need for broader adoption of the aforementioned 7 guiding principles along with the development of additional simple and safe CTO crossing and revascularization strategies through ongoing research, education, and training.

Original languageEnglish
Pages (from-to)420-433
Number of pages14
Issue number5
Publication statusPublished - 2019 Jul 30

Bibliographical note

Funding Information:
Dr Brilakis: Consulting/speaker honoraria from Abbott Vascular, American Heart Association (associate editor Circulation), Boston Scientific, Cardiovascular Innovations Foundation (Board of Directors), CSI, Elsevier, GE Healthcare, InfraRedx, and Medtronic; research support from Regeneron and Siemens. Shareholder: MHI Ventures. Board of Trustees: Society of Cardiovascular Angiography and Interventions. Dr Mashayekhi: Consulting/speaker/proctoring honoraria from Abbott Vascular, Ashai Intecc, AstraZeneca, Biotronik, Boston Scientific, Cardinal Health, Daiichi Sankyo, Medtronic, Teleflex, Terumo. Dr Tsuchikane: Consultant of Boston Scientific, Asahi Intecc, Nipro, and Kaneka. Dr Abi Rafeh: CTO Proctor and consultant for Boston Scientific and Abbott Vascular. Dr Alaswad: consultant and speaker for Boston Scientific, Abbott Cardiovascular, CSI, and LivaNova. Dr Avran: Proctor for Boston Scientific, Biotronik, Abbott, Terumo, Biosensor, Medtronic. Dr Azzalini: Honoraria from Abbott Vascular, Guerbet, Terumo, and Sahajanand Medical Technologies; research support from ACIST Medical Systems, Guerbet, Terumo. Dr Boudou: Proctorship fees from Boston Scientific, Terumo, Abbott Vascular, and Biotronik. Dr Buller: Intellectual property: Teleflex; consultant: Abbott Vascular, Soundbite Medical, and Philips-Volcano. Dr Burke: Consulting and speaker honoraria from Abbott Vascular and Boston Scientific. Dr Croce: Proctor/speaking honoraria: Abbott, Boston Scientific, CSI, Philips; research grant: Teleflex, Takeda; advisory board: Abiomed, Cordis. Dr de los Santos: Speaker and proctor of Boston Scientific, Terumo, and Abbott. Dr De Martini: Proctor and advisory board for Abbott and Boston Scientific. Dr Dens: Consulting/speaker honoraria from Abbott Vascular, Boston Scientific, IMDS, Orbus Neich, Terumo, and Topmedical (distributor for Asahi). Dr Di Mario: research grant to institution from Amgen, Behring, Chiesi, Daiichi Sankyo, Edwards, Medtronic, Shockwave. Dr Egred: Honoraria, speaker and proctorship fees from Abbott Vascular, Boston Scientific, Vascular Perspectives, Philips/Volcano, Biosensors, and EPS. Dr ElGuindy: Proctorship fees from Boston Scientific. Dr Gagnor: Consultant Boston Scientific, Terumo. Dr Garbo: Consultant Boston Scientific, Terumo, Philips Volcano, IMDS, and CID-Alvimedica. Dr Grantham: Speaking fees, travel reimbursement, and honoraria from Boston Scientific, Abbott Vascular, and Asahi Intecc. Institutional research grants Boston Scientific. Part-time employment and equity in Corindus Vascular Robotics. Dr Hanratty: Proctoring for Abbott, Boston Scientific, Medtronic, and Teleflex. Dr Harb: Consultant with Medtronic, speaker´s honoraria from Medtronic and Cardinal Health. Dr Harding: Proctor/speaker for Boston Scientific, Abbott Vascular, and Bio-Excel; consultant/speaker for Medtronic and Asahi. Dr Hill: Speaker, consultant, and proctor for Boston Scientific and Abbott Vascular. Dr Jaffer: Sponsored research from Canon, and Siemens; consultant for Boston Scientific, Abbott Vascular, Siemens, and Philips. Massachusetts General Hospital has a patent licensing arrangement with Canon, and Dr Jaffer has the right to receive royalties. Dr Jussila: Consulting agreement with EPS Vascular, Boston Scientific, and Terumo. Dr Kalyanasundaram: Speaker, consultant, and proctor for Boston Scientific, Asahi, and Abbott Vascular. Dr Kandzari: Research/grant support: Medtronic, Boston Scientific, Biotronik; consulting honoraria: Medtronic, Boston Scientific, Biotronik, and CSI. Dr Kao: Speaker/proctor honoraria: Abbott Vascular, Asahi Intecc, Biotronik, Boston Scientific, Medtronic, Orbus Neich, and Terumo. Dr Karmpaliotis: Honoraria Boston Scientific, Abiomed and Abbott Vascular. Dr Kornowski: Co-founder of NitiLoop. Dr Krestyaninov: Speaker and proctor honoraria from Abbott Vascular. Dr Laanmets: Consultant for Terumo. Dr Lee: Speaker and proctorship honoraria from Abbott Vascular, Boston Scientific, and Medtronic. Dr Lefevre: Proctoring for Terumo. Dr Lim: Travel support from Asahi Intecc, Terumo, Kaneka, Boston Scientific, and Abbott Vascular. Dr Lo: Travel support from Bioexcel and Abbott; speaker honoraria from Abbott, Boston Scientific, and Bioexcel; proctorshop fees from Bioexcel and Boston Scientific. Dr Lombardi: Speaking fees, honoraria, and travel expense reimbursement from Boston Scientific, Asahi-Intecc, Teleflex, Siemens, and Abbott Vascular; equity holder in Corindus Vascular Robotics; spouse employed by Phillips. Dr Nicholson: Advisory boards and consulting: Abbott Vascular, Boston Scientific, Medtronic, and Corindus. Dr Olivecrona: Lecture/proctor honoraria: Biotronik, EPS vascular, Biosensors, and Edwards Lifesciences. Dr Postu: Advisory board: Medtronic; proctor: Boston Scientific; consultant: Terumo. Dr Quadros: Education support from Medtronic, Abbott Vascular, Boston Scientific, and Biotronic, and research grants from Medtronic. Dr Quesada: Proctor for Boston Scientific. Dr Saghatelyan: Consulting/speaker honoraria from Asahi Intecc. Dr Trinidad: Proctor and Speaker for Boston Scientific and Abbott Vascular. Dr Smith: Speaker fees, honoraria, proctorship fees, Boston Scientific, Abbott Vascular, Vascular Perspectives, and Biosensors International. Dr Stone: Reports having served as a consultant to: Matrizyme, Miracor, Neovasc, V-wave, Shockwave, Valfix, TherOx, Reva, Vascular Dynamics, Robocath, HeartFlow, Gore, Ablative Solutions, and Ancora; having received speaker honoraria from Amaranth and Terumo; holding equity in Ancora, Cagent, Qool Therapeutics, Aria, Caliber, MedFocus family of funds, Biostar family of funds, Applied Therapeutics, and SpectraWAVE; serving as a director in SpectraWAVE; and that his employer, Columbia University, receives royalties for sale of the MitraClip from Abbott. Dr Strange: Consulting fees from Abbott and Boston Scientific. Dr Tammam: Proctor for Boston Scientific, Terumo and Asahi. Dr Ungi: CTO Proctor and consultant for Boston Scientific. Dr Vo: Consultant for Abbott Vascular, Canadian Hospital Specialties, and Teleflex. Dr Wollmuth: Proctor/consultant for Abbott Vascular, Boston Scientific, and Asahi Intecc. Dr Wu: Consultant fees and speaker honorarium from Abbott and Boston Scientific, and research grant from Asahi. Dr Wyman: Consultant/honoraria from Abbott, Abiomed, and Boston Scientific. Dr Yeh: Consulting/advisory board: Abbott Vascular, Asahi Intecc, Boston Scientific, Medtronic, and Teleflex. Research grants: Abbott Vascular, Abiomed, and Boston Scientific. Dr Rinfret: Research support from SoundBite Medical; consultant, proctor and/or speaker for Abiomed, Boston Scientific, Abbott, and Teleflex. The other authors report no conflicts.

Publisher Copyright:
© 2019 American Heart Association, Inc.

All Science Journal Classification (ASJC) codes

  • Cardiology and Cardiovascular Medicine
  • Physiology (medical)


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