Problems encountered in retrograde recanalization of coronary chronic total occlusion: Should we lock the backdoor in 2018?

A step-by-step guide to mastering retrograde coronary chronic total occlusion intervention in 2018: The author's perspective

Chronic total occlusion remains one of the most challenging subsets and represents the "last frontier" of percutaneous coronary intervention. Retrograde recanalization is one of the most significant amendments of the technique and has become an important complement to the classical antegrade approach. It yields a high success rate even in most complex patients. With emergence of important iterations, this approach has become safer, faster, and more successful. The author proposes a step-by-step guide to the retrograde approach with alternatives to various steps for operators wishing to embark on this strategy.

Coronary chronic total occlusion intervention: A pathophysiological perspective

Percutaneous coronary intervention (PCI) of chronic total occlusion (CTO) is the last frontier in coronary intervention. PCI of CTO carries multiple advantages, such as significant improvement in symptoms, improvement in abnormal wall motion and left ventricular function and, possibly, increased long-term survival. As of today the procedural success is markedly improved because of technical innovations and is limited to highly experienced operators. To enhance the overall success rate from a worldwide perspective, a thorough understanding of its pathophysiology is critical to further development of newer techniques and technologies. In this review, the author outlines in-depth the evidence that underpins our understanding of CTO pathophysiology and its insight into CTO intervention that incorporates various steps and techniques to cross the lesion.

Interventional Management of "Balloon-Uncrossable" Coronary Chronic Total Occlusion: Is There Any Way Out?

It has been estimated that coronary chronic total occlusion (CTO) is encountered in 15 to 20% patients referred for coronary angiography (CAG). The success of percutaneous coronary intervention (PCI) of CTO can be attributed to the vast array of hardware that has now become available and also to the vastly enhanced operator expertise. It is however realistic to state that despite the tremendous increase in the rate of success, there then comes a subset of CTO where PCI attempts fail. The reason for such failures given that other variables remain constant is the inability to cross the CTO lesion. This can be due to a failure to cross the lesion with a guide wire (despite guide wire escalation). The second cause of failure is the inability to cross the lesion with a balloon (balloon-uncrossable [BU] CTO). This can occur despite the successful placement of a guidewire in the distal true lumen. The BU lesions contribute 2% to 10% of CTO PCI failure cases. The author attempts to present a creative solution to assist crossing such lesions.