The Chronic Total Occlusion

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Overview

PCI Approaches:

CAD Revascularization:

Heart Team Approach to Revascularization Decisions
Left Main Coronary Artery Disease
Intervention in left main coronary artery disease
Non-Left Main Coronary Artery Disease
Revascularization to Improve Symptoms
Dual Antiplatelet Therapy Compliance and Stent Thrombosis
Hybrid Coronary Revascularization

Pre-procedural Considerations:

Contrast-Induced Acute Kidney Injury
Anaphylactoid Reactions
Statin Treatment
Bleeding Risk
Role of Onsite Surgical Backup

Procedural Considerations:

Vascular Access
PCI in Specific Clinical Situations:
Asymptomatic Ischemia or CCS Class I or II Angina
CCS Class III Angina
Unstable Angina/Non–ST-Elevation Myocardial Infarction
ST-Elevation Myocardial Infarction:
General and Specific Considerations
Coronary Angiography Strategies in STEMI
Primary PCI of the Infarct Artery
Delayed or Elective PCI in patients with STEMI
Fibrinolytic-Ineligible Patients
Facilitated PCI
Rescue PCI
After Successful Fibrinolysis or for Patients Not Undergoing Primary Reperfusion
Cardiogenic Shock
Prior Coronary Bypass Surgery
Revascularization Before Non-cardiac Surgery
Adjunctive Diagnostic Devices:
Fractional Flow Reserve
Intravascular Ultrasound
Adjunctive Therapeutic Devices:
Coronary Atherectomy
Thrombectomy
Laser Angioplasty
Cutting Balloon Angioplasty
Embolic Protection Devices
Percutaneous Hemodynamic Support Devices
Antiplatelet therapy:
Oral Antiplatelet Therapy
Glycoprotein IIb/IIIa Receptor Antagonists
Intravenous Antiplatelet therapy:
STEMI
UA/NSTEMI
SIHD
Anticoagulant Therapy:
Parenteral Anticoagulants During PCI
Unfractionated Heparin
Enoxaparin
Bivalirudin and Argatroban
Fondaparinux
No-Reflow Pharmacological Therapies
PCI in Specific Anatomic Situations:
Chronic Total Occlusions
Saphenous Vein Grafts
Bifurcation Lesions
Aorto-Ostial Stenoses
Calcified Lesions
PCI in Specific Patient Populations:
Chronic Kidney Disease
Peri-procedural Myocardial Infarction Assessment
Vascular Closure Devices

Post-Procedural Considerations:

Post-procedural Antiplatelet Therapy
Proton Pump Inhibitors and Antiplatelet Therapy
Clopidogrel Genetic Testing
Platelet Function Testing
Restenosis
Exercise Testing
Cardiac Rehabilitation

Quality and Performance Considerations:

Quality and Performance
Certification and Maintenance of Certification
Operator and Institutional Competency and Volume

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Anum Ijaz M.B.B.S., M.D.[2]

Overview

A coronary chronic total occlusion is a completely occluded epicardial coronary artery with no antegrade flow through the occluded segment and an estimated occlusion duration of at least three months. The lesion is found in roughly one in five patients with significant coronary artery disease at diagnostic angiography, yet only a minority of these patients are offered percutaneous revascularization, and dedicated percutaneous coronary intervention for the occlusion remains among the most technically demanding procedures in interventional cardiology.

The purpose of chronic total occlusion percutaneous coronary intervention is to relieve angina and its equivalents, to improve disease-specific quality of life and to complete revascularization. It has not been shown to reduce death or myocardial infarction, and guideline recommendations remain deliberately cautious on that point. The strongest evidence for symptomatic benefit comes from blinded, placebo-controlled testing, which demonstrates a real but moderate reduction in angina burden, with residual symptoms in a proportion of treated patients.

Case selection rests on three questions answered before the patient reaches the table: whether symptoms persist despite optimal medical therapy, whether the territory subtended by the occlusion is ischaemic and viable, and whether the anatomy is crossable by an operator with the necessary technique set. Angiographic assessment is performed on dual injection and addresses the proximal cap, the occlusion segment, the distal vessel and the collateral circulation; scoring systems translate these features into an expected probability of crossing and of procedural success. Crossing itself follows a staged algorithm that moves between antegrade wiring, antegrade dissection and re-entry, and the retrograde approach, with a deliberate change of strategy rather than persistence when the initial approach fails.

Chronic total occlusion percutaneous coronary intervention carries a higher complication burden than conventional percutaneous coronary intervention, and the specific hazards - coronary artery perforation and cardiac tamponade, donor vessel injury, equipment entrapment, contrast-induced nephropathy and radiation injury - drive both the case-selection process and the pre-agreed limits at which an attempt is abandoned in favour of a staged re-attempt.

Epidemiology and Demographics

Indications for Chronic Total Occlusion Percutaneous Coronary Intervention

  • The purpose of the procedure is relief of ischaemic symptoms; angina or an anginal equivalent such as dyspnoea; and completion of revascularization; it should not be offered on the expectation of reducing death or myocardial infarction.[3][2]
  • Candidates should have symptoms that persist despite optimal medical therapy, demonstrated ischaemia in the territory subtended by the occlusion, and viable myocardium in that territory.[4]
  • Non-invasive imaging should establish both the extent of ischaemia and the presence of viable myocardium before the procedure is planned; an ischaemic burden of at least 10% of the left ventricle and a comparable extent of viable or hibernating myocardium are the thresholds used to identify patients most likely to benefit.[4]
  • Non-obstructive lesions in the same vessel and all non-occlusive disease should be addressed first, so that residual symptoms can be attributed to the occlusion itself before it is attempted.[5]
  • The procedure should be performed only by operators with the relevant expertise, and complex anatomy should be referred to an operator or centre with a dedicated chronic total occlusion practice rather than attempted opportunistically.[6][7]

Evidence for Symptomatic Benefit

  • Successful recanalization reduces angina frequency, increases the number of angina-free days and improves disease-specific quality of life when tested against a blinded sham procedure, so the symptomatic benefit is not attributable to the placebo effect of an invasive procedure alone.[8]
  • The magnitude of that benefit is moderate rather than dramatic, and patients should be counselled that residual angina requiring continued antianginal therapy is common after a technically successful procedure.[8]
  • Unblinded randomised comparison against optimal medical therapy alone also shows improvement in angina frequency and quality of life.[9]
  • Randomised comparison has not demonstrated a reduction in major adverse cardiac events with recanalization compared with optimal medical therapy alone, and the largest such trial was terminated before its recruitment target was reached, leaving it underpowered for hard endpoints.[10]
  • Recanalization of a concurrent chronic total occlusion after primary percutaneous coronary intervention for ST elevation myocardial infarction has not been shown to improve major adverse cardiac events, so a bystander occlusion identified during an acute presentation is not by itself an indication to proceed.[11]
  • Observational series consistently show improvement in Canadian Cardiovascular Society angina class and in angina frequency, nitrate use and treatment satisfaction after successful recanalization, without a difference in mortality between successful and failed attempts.[12]
  • In patients with reduced left ventricular ejection fraction and viable myocardium in the occluded territory, left ventricular ejection fraction improves after successful recanalization in a substantial minority, but this is registry-level evidence and should not be presented to the patient as an established benefit.[2]
  • The European consensus position is that percutaneous recanalization should be considered in selected patients with angina resistant to medical therapy; this is expressed as a consensus recommendation rather than as a change to the American guideline position below.[3][4]

Lesion Assessment

  • Dual and in patients with prior coronary artery bypass grafting, triple injection should be performed before any attempt, injecting the donor vessel first and the occluded vessel two to three seconds later so that the proximal and distal caps are opacified simultaneously.[13][14]
  • Four angiographic parameters should be assessed on every case and recorded before wiring: proximal cap morphology and location, the occlusion segment (length, course, tortuosity and calcification), distal vessel size and disease burden, and the collateral circulation.[13][14]
  • A large, disease-free distal vessel increases the likelihood that an antegrade technique will succeed; a small or poorly visualized distal vessel lowers overall success and should prompt consideration of the retrograde approach.[14]
  • Collateral connections should be graded angiographically as CC0 where no continuous connection is seen, CC1 where a threadlike continuous connection is present, and CC2 where the connection is side-branch-like; the grade predicts whether the collateral can be wired.[15]
  • Collateral crossing succeeds more often through side-branch-like connections than through threadlike or absent connections, and bypass grafts and septal collaterals should be preferred over epicardial connections, which carry the highest perforation risk.[2][14]
  • The J-CTO score assigns one point each for a blunt entry stump, calcification, a bend greater than 45 degrees within the occlusion, occlusion length greater than 20 mm and a previous failed attempt, and predicts guidewire crossing within 30 minutes; a score of 2 or more identifies a lesion for which proctoring or referral should be considered.[16]
  • Procedural success can be graded separately from crossing difficulty using a registry-derived success score, which should be used to set expectations with the patient and to decide whether the case belongs in a dedicated programme.[17]
  • The PROGRESS-CTO technical success score assigns one point each for proximal cap ambiguity, moderate or severe proximal vessel tortuosity, a circumflex occlusion and the absence of an interventional collateral, and is the score most widely used alongside the J-CTO score in contemporary Western practice.[18][19]
  • Periprocedural complication risk should be estimated separately from technical success, using a registry-derived complication score, and discussed with the patient before consent rather than inferred from the difficulty score alone.[20]
  • Crossing strategies and periprocedural complications should be recorded using the harmonized CTO-ARC definitions, because the strategy labels used in older series are not interchangeable: reclassifying a large European registry to those definitions separated out an "alternative antegrade crossing" category, used almost entirely as a rescue strategy, whose technical success is far lower and complication rate far higher than true antegrade crossing.[21]
  • Preprocedural coronary computed tomography angiography should be obtained for complex occlusions — in practice those with a J-CTO score of 2 or more — where it improves crossing and procedural success compared with angiographic planning alone.[22][14]
  • Computed tomography derived scores from the CT-RECTOR and Korean multicentre registries should be used where a coronary computed tomography angiography has been obtained, since they predict procedural success from features that are not fully assessable on angiography alone.[23]
  • Artificial-intelligence-enhanced analysis of coronary computed tomography angiography is emerging as a planning adjunct, including registration of the computed tomography dataset to the live angiography image; it should be regarded as investigational rather than established practice.[24]
  • Moderate or severe calcification, proximal vessel tortuosity and a bifurcation within the occluded segment each reduce technical and procedural success and increase in-hospital major adverse cardiac events, cardiac tamponade and coronary artery perforation; circumferential "full moon" calcification is the most adverse of these features.[2]

Treatment

  • Technical success in contemporary European practice is approximately 89%, but it is strategy-dependent: close to 93% where the occlusion is crossed antegradely and close to 79% where a retrograde approach is used, and this difference reflects case selection as much as technique.[25]
  • Lower centre procedure volume is an independent predictor of periprocedural complications, alongside the retrograde approach, female sex and older age.[25]

Vascular Access and Procedural Setup

  • Dual arterial access is required so that both the occluded vessel and the donor vessel can be injected and instrumented.[13]
  • Radial access should be preferred where the required equipment can be delivered, because randomised comparison shows fewer access-site complications than femoral access without loss of procedural success; distal radial access performs comparably to conventional radial access in registry data.[14]
  • Access-site complications occur in approximately 1% of chronic total occlusion procedures and are more frequent with femoral access, sheaths of 7 French or larger, older age, female sex and the need for urgent mechanical circulatory support.[2]

Antegrade Crossing Strategies

  • Antegrade wiring should be the initial strategy in most cases, with wire escalation proceeding from soft, tapered, polymer-jacketed wires to progressively stiffer wires as the cap resists.[13][14]
  • Where the initial wire enters an unfavourable plane, parallel wiring should be used before abandoning the antegrade approach; it achieves comparable success to antegrade dissection and re-entry with fewer complications and less radiation and contrast.[2]
  • Where the proximal cap is ambiguous, the cap should be located by intravascular ultrasound-guided puncture or by "moving the cap" with a deliberate proximal dissection, or the case should be converted to a retrograde approach, rather than by continued blind wiring.[13][14]

Antegrade Dissection and Re-entry

  • Antegrade dissection and re-entry is suited to long occlusions in practice those exceeding 20 mm that are calcified or tortuous, provided the distal vessel is of good quality and there is no major side branch in the re-entry zone.[14]
  • It should not be used where the distal cap sits at a bifurcation whose side branch would be lost, and its use has declined as antegrade wiring and retrograde techniques have matured.[14][2]
  • Registry data associate antegrade dissection and re-entry with lower technical success and higher in-hospital major adverse cardiac events than other crossing strategies, so it should be selected for the anatomy that favours it rather than used as a default escalation step.[2]
  • Tip-detection antegrade dissection and re-entry, in which re-entry is directed by intravascular ultrasound, has produced higher device success with shorter procedure times and lower radiation than balloon-facilitated re-entry in single-centre series, and should be regarded as promising but supported only by observational data.[2]

Retrograde Approach

  • The retrograde approach should be selected where the proximal cap is ambiguous, where the distal vessel is poorly visualized or small, where the distal cap sits at a bifurcation, where the occlusion is long, where proximal vessel engagement is difficult, or where renal impairment favours the lower contrast requirement and in all cases only where an interventional collateral is available.[13][26]
  • Septal collaterals should be the first choice of retrograde conduit; they carry a low cardiac tamponade risk and can be dilated if necessary.[26]
  • Epicardial collaterals are the route of last resort, must not be dilated, and carry the highest risk of coronary artery perforation and cardiac tamponade.[26]
  • Retrograde true lumen crossing should be preferred wherever it is feasible, because it carries the lowest rate of major adverse cardiac events of any retrograde technique.[27]
  • Where true lumen crossing is not possible, reverse controlled antegrade and retrograde tracking is the principal dissection and re-entry technique and the most frequently used retrograde crossing method in contemporary registries; its contemporary and extended variants carry lower event rates than the conventional form, and under-sizing the antegrade balloon is the commonest reason it fails.[27][26][2]
  • Retrograde crossing itself succeeds in roughly 60% of attempts and the lesion is ultimately crossed in about 80%; where the retrograde attempt fails, antegrade salvage succeeds in about half of cases, so failure of the retrograde wire is not by itself a reason to abandon the procedure.[27]
  • The retrograde wire should be externalized through the antegrade guide before stenting, with the retrograde microcatheter left across the collateral to protect it during wire manipulation.[26]
  • Non-externalizing "portal" techniques: tip-in, balloon-assisted tip-in, rendezvous and related methods reduce collateral manipulation and should be considered where the collateral is fragile.[2]
  • The retrograde approach carries substantially higher rates of coronary artery perforation and cardiac tamponade than antegrade crossing, and this should be weighed explicitly at the point the strategy is chosen rather than after the antegrade approach has already consumed time and contrast.[2]

Intravascular Imaging Guidance

  • Intravascular ultrasound should be used to locate an ambiguous proximal cap, to confirm the wire position relative to the true lumen, and to guide and optimise stent implantation.[2][13]
  • Intravascular imaging guidance reduces target lesion failure and target vessel revascularization compared with angiography alone in chronic total occlusion percutaneous coronary intervention, and failure to meet post-implantation optimisation targets carries a markedly higher risk of subsequent target vessel failure.[2]
  • Intravascular imaging use is also associated with a lower risk of coronary artery perforation, and should be regarded as a safety measure as well as an optimisation tool.[2]

Drug-Coated Balloons and Hybrid Strategies

  • Restenosis and stent failure after drug-eluting stent implantation in a recanalized chronic total occlusion occur in roughly 14% to 30% of cases, which is the problem that balloon-based alternatives are intended to address.[28]
  • Drug-coated balloon angioplasty, used alone or combined with a drug-eluting stent in a hybrid strategy, may be considered for both de novo and in-stent chronic total occlusions: it has not produced a difference in target lesion revascularization, death or myocardial infarction compared with stenting, but the comparison rests on a small number of mostly non-randomised studies and should not be regarded as established.[28]
  • Late luminal enlargement is consistently observed in the months after drug-coated balloon treatment, so an acceptable but unimpressive acute angiographic result does not by itself mandate bailout stenting.[28]

Adjunctive Antithrombotic Therapy

  • Unfractionated heparin should be used rather than a direct thrombin inhibitor as the default anticoagulant, dosed at 70 to 100 units per kilogram, because it can be reversed with protamine if coronary artery perforation occurs.[29]
  • The guideline target for unfractionated heparin in elective percutaneous coronary intervention is an activated clotting time of 250 to 300 seconds on HemoTec or i-STAT devices, with goals approximately 50 seconds higher on Hemochron devices, and a higher target should be considered specifically for chronic total occlusion.[5]
  • Consensus practice in chronic total occlusion is to maintain an activated clotting time above 300 seconds for antegrade cases and above 350 seconds for retrograde cases — on HemoTec or i-STAT devices, with targets approximately 50 seconds higher on Hemochron devices — rechecked every 20 to 30 minutes.[29][30][31]
  • Registry data do not support pushing the activated clotting time to the upper end of that range: values below 200 seconds and above 400 seconds are both associated with higher net adverse cardiovascular events than values between 200 and 400 seconds. This conflicts with the higher consensus targets above and is unsettled.[2][29]
  • Glycoprotein IIb/IIIa inhibitors should be avoided during chronic total occlusion percutaneous coronary intervention, because an unrecognized coronary artery perforation may progress to cardiac tamponade; their use may be considered only for donor vessel thrombosis during a retrograde attempt.[29]
  • Protamine should be given at 1 to 1.5 mg per 100 units of administered heparin to a maximum of 50 mg, at no more than 5 mg per minute, and only after mechanical measures to control a coronary artery perforation have been attempted.[29]
  • Aspirin with clopidogrel for six months followed by aspirin indefinitely is the default regimen after elective chronic total occlusion percutaneous coronary intervention in stable coronary artery disease; a potent P2Y12 inhibitor should replace clopidogrel where the occlusion is a bystander in an acute coronary syndrome or where the anatomy treated is complex.[29]
  • Routinely extending dual antiplatelet therapy beyond the standard duration has not been shown to improve clinical outcomes in this population, and duration should be individualised to ischaemic and bleeding risk.[29]

Procedural Limits and the Investment Procedure

  • Pre-agreed limits should be set before the case begins and adhered to: the attempt should stop at approximately three hours of procedure time, at a contrast volume exceeding three times the glomerular filtration rate, or at an air kerma dose above 5 Gy.[14]
  • The attempt should also stop earlier than these limits for a major complication, or where crossing requires a technique outside the operator's competence.[14]
  • Where crossing into the distal true lumen fails, balloon dilatation of the subintimal space should be considered as an "investment" procedure, with a planned re-attempt at approximately eight weeks, rather than persisting to the point of complication.[14]
  • Radiation dose should be tracked and reduced actively; contemporary registries report a median air kerma of about 2 Gy, with higher doses in patients with elevated body mass index, in women, after prior coronary artery bypass grafting and with retrograde crossing.[2]

2011 ACCF/AHA/SCAI Guidelines for Percutaneous Coronary Intervention (DO NOT EDIT)[6]

Chronic Total Occlusions (DO NOT EDIT)[6]

Class IIa
"1. PCI of a chronic total occlusion in patients with appropriate clinical indications and suitable anatomy is reasonable when performed by operators with appropriate expertise.[32][33][34][35][36] (Level of Evidence: B)"

2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization (DO NOT EDIT)[5]

Chronic Total Occlusion (DO NOT EDIT)[5]

Class IIb
"1. In patients with suitable anatomy who have refractory angina on medical therapy, after treatment of non-CTO lesions, the benefit of PCI of a CTO to improve symptoms is uncertain. (Level of Evidence: B-R)"

Complications

  • Coronary artery perforation is the characteristic complication, occurring in approximately 4% of contemporary European procedures overall: roughly 8% where a retrograde approach is used and 2% where crossing is antegrade — and in a higher proportion of heavily calcified lesions.[25][2]
  • Retrograde-attributed perforation rates overstate the risk of the retrograde stage itself: where both approaches are used in the same case, most perforations occur during the antegrade phase, so the operator should not relax vigilance simply because the retrograde wire has not yet been advanced.[37]
  • Roughly half of perforations require no treatment beyond observation; those that do should be managed by covered stent for a large vessel, and by coil or fat embolization for a distal or small vessel.[37][2]
  • Perforations that are large, proximally located or in a collateral carry the highest risk of major adverse cardiac events and should be treated rather than observed.[37]
  • Cardiac tamponade occurs in under 1% of procedures overall: approximately 1.5% of retrograde and 0.4% of antegrade cases and pericardiocentesis is required in about 1% of all cases.[25][2]
  • "Dry" tamponade: haemodynamic collapse without a free-flowing pericardial effusion, typically from a dissecting intramyocardial haematoma should be recognized as a distinct entity, since it is difficult to drain percutaneously and carries a high mortality.[2]
  • Donor vessel injury is uncommon but consequential: it occurs in under 0.5% of procedures yet is followed by markedly lower procedural success and much higher rates of major adverse cardiac events, periprocedural myocardial infarction and death.[2]
  • Equipment entrapment or loss occurs in under 0.5% of procedures, and retrieval of the retained item succeeds in fewer than half of attempts, so equipment should be advanced and withdrawn with the collateral protected.[2]
  • Access-site complications occur in approximately 1% of procedures, most often as haematoma, with pseudoaneurysm and acute arterial closure less common.[2]
  • Contrast-induced nephropathy and radiation injury are procedure-length-dependent hazards, and the contrast and air kerma limits in the section above exist to bound them.[14]
  • In patients with prior coronary artery bypass grafting, technical and procedural success are lower and coronary artery perforation, periprocedural myocardial infarction and in-hospital death more frequent, although prior bypass surgery is not independently associated with adverse outcome once lesion complexity is accounted for.[2]

References

  1. ↑ Fefer P, Knudtson ML, Cheema AN, Galbraith PD, Osherov AB, Yalonetsky S, Gannot S, Samuel M, Weisbrod M, Bierstone D, Sparkes JD, Wright GA, Strauss BH (2012). "Current Perspectives on Coronary Chronic Total Occlusions: The Canadian Multicenter Chronic Total Occlusions Registry". Journal of the American College of Cardiology. 59 (11): 991–7. doi:10.1016/j.jacc.2011.12.007. PMID 22402070. Unknown parameter |month= ignored (help); |access-date= requires |url= (help)
  2. ↑ 2.00 2.01 2.02 2.03 2.04 2.05 2.06 2.07 2.08 2.09 2.10 2.11 2.12 2.13 2.14 2.15 2.16 2.17 2.18 2.19 2.20 2.21 2.22 2.23 2.24 2.25 2.26 Ceylan S, Mutlu D, Kladou E, Williford N, Jalli S, Al-Ogaili A, Yamane M, Alaswad K, Hall A, Davies R, Choi J, Gagnor A, Garbo R, Goktekin O, Gorgulu S, Khatri J, Nicholson W, Rinfret S, Jaber W, Egred M, Milkas A, Ciardetti N, Di Mario C, Mashayekhi K, Avran A, Leibundgut G, Chatzizisis Y, Werner G, Ungureanu C, Sandoval Y, Brilakis ES (2026). "Chronic Total Occlusion Percutaneous Coronary Intervention: 2026 Update". Journal of Invasive Cardiology. doi:10.25270/jic/25.00301. Unknown parameter |month= ignored (help); |access-date= requires |url= (help)
  3. ↑ 3.0 3.1 Galassi AR, Vadalà G, Werner GS, Cosyns B, Sianos G, Hill J, Dudek D, Picano E, Novo G, Andreini D, Gerber BL, Buechel R, Mashayekhi K, Thielmann M, McEntegart MB, Vaquerizo B, Di Mario C, Stojkovic S, Sandner S, Bonaros N, Maurovich-Horvat P, Gaemperli O, Sousa-Uva M, Neskovic AN, Pontone G, Achenbach S, Petersen SE, Prescott E, Saraste A (2024). "Evaluation and management of patients with coronary chronic total occlusions considered for revascularisation. A clinical consensus statement of the European Association of Percutaneous Cardiovascular Interventions (EAPCI) of the ESC, the European Association of Cardiovascular Imaging (EACVI) of the ESC, and the ESC Working Group on Cardiovascular Surgery". EuroIntervention. 20 (3): e174–e184. doi:10.4244/EIJ-D-23-00749. Unknown parameter |month= ignored (help); |access-date= requires |url= (help)
  4. ↑ 4.0 4.1 4.2 Hamzaraj K, Kammerlander A, Gyöngyösi M, Frey B, Distelmaier K, Graf S (2022). "Patient Selection and Clinical Indication for Chronic Total Occlusion Revascularization—A Workflow Focusing on Non-Invasive Cardiac Imaging". Life. 13 (1): 4. doi:10.3390/life13010004. Unknown parameter |month= ignored (help); |access-date= requires |url= (help)
  5. ↑ 5.0 5.1 5.2 5.3 Lawton JS, Tamis-Holland JE, Bangalore S, Bates ER, Beckie TM, Bischoff JM, Bittl JA, Cohen MG, DiMaio JM, Don CW, Fremes SE, Gaudino MF, Goldberger ZD, Grant MC, Jaswal JB, Kurlansky PA, Mehran R, Metkus TS, Nnacheta LC, Rao SV, Sellke FW, Sharma G, Yong CM, Zwischenberger BA (2022). "2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines". Journal of the American College of Cardiology. 79 (2): e21–e129. doi:10.1016/j.jacc.2021.09.006. PMID 34895950 Check |pmid= value (help). Unknown parameter |month= ignored (help); |access-date= requires |url= (help)
  6. ↑ 6.0 6.1 6.2 Levine GN, Bates ER, Blankenship JC, Bailey SR, Bittl JA, Cercek B, Chambers CE, Ellis SG, Guyton RA, Hollenberg SM, Khot UN, Lange RA, Mauri L, Mehran R, Moussa ID, Mukherjee D, Nallamothu BK, Ting HH (2011). "2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention: Executive Summary A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Society for Cardiovascular Angiography and Interventions". Journal of the American College of Cardiology. 58 (24): 2550–83. doi:10.1016/j.jacc.2011.08.006. PMID 22070837. Unknown parameter |month= ignored (help); |access-date= requires |url= (help)
  7. ↑ Brilakis ES, Mashayekhi K, Tsuchikane E, Abi Rafeh N, Alaswad K, Araya M, Avran A, Azzalini L, Babunashvili AM, Bayani B, Bhindi R, Boudou N, Boukhris M, Božinović NŽ, Bryniarski L, Bufe A, Buller CE, Burke MN, Büttner A, Cardoso P, Carlino M, Christiansen EH, Colombo A, Croce K, Damas de los Santos F, De Martini T, Dens J, Di Mario C, Dou K, Egred M, ElGuindy AM, Escaned J, Furkalo S, Gagnor A, Galassi AR, Garbo R, Ge J, Goel PK, Goktekin O, Grancini L, Grantham JA, Hanratty C, Harb S, Harding SA, Henriques JPS, Hill JM, Jaffer FA, Jaber W, Jussila R, Kalnins A, Kalyanasundaram A, Kandzari DE, Kao HL, Karmpaliotis D, Kassem HH, Knaapen P, Kornowski R, Krestyaninov O, Kumar AVG, Laanmets P, Lamelas P, Lee SW, Lefevre T, Li Y, Lim ST, Lo S, Lombardi W, McEntegart M, Munawar M, Navarro Lecaro JA, Ngo HM, Nicholson W, Olivecrona GK, Padilla L, Postu M, Quadros A, Quesada FH, Prakasa Rao VS, Reifart N, Saghatelyan M, Santiago R, Sianos G, Smith E, Spratt JC, Stone GW, Strange JW, Tammam K, Ungi I, Vo M, Vu VH, Walsh S, Werner GS, Wollmuth JR, Wu EB, Wyman RM, Xu B, Yamane M, Ybarra LF, Yeh RW, Zhang Q, Rinfret S (2019). "Guiding Principles for Chronic Total Occlusion Percutaneous Coronary Intervention: A Global Expert Consensus Document". Circulation. 140 (5): 420–33. doi:10.1161/CIRCULATIONAHA.119.039797. PMID 31356129. Unknown parameter |month= ignored (help); |access-date= requires |url= (help)
  8. ↑ 8.0 8.1 Khan S, Sajjad U, Fawaz S, Butt H, Simpson R, Ibrahim A, Cook CM, Rajkumar CA, Al-Lamee R, Karamasis GV, Keeble TR, Davies JR (2026). "Randomized, Placebo-Controlled Trial of Chronic Total Occlusion Percutaneous Coronary Intervention in Stable Angina: The ORBITA-CTO Trial". Journal of the American College of Cardiology. 88 (1): 4–18. doi:10.1016/j.jacc.2026.03.027. PMID 41999379 Check |pmid= value (help). Unknown parameter |month= ignored (help); |access-date= requires |url= (help)
  9. ↑ Werner GS, Martin-Yuste V, Hildick-Smith D, Boudou N, Sianos G, Gelev V, Rumoroso JR, Erglis A, Christiansen EH, Escaned J, di Mario C, Hovasse T, Teruel L, Bufe A, Lauer B, Bogaerts K, Goicolea J, Spratt JC, Gershlick AH, Galassi AR, Louvard Y (2018). "A randomized multicentre trial to compare revascularization with optimal medical therapy for the treatment of chronic total coronary occlusions". European Heart Journal. 39 (26): 2484–93. doi:10.1093/eurheartj/ehy220. Unknown parameter |month= ignored (help); |access-date= requires |url= (help)
  10. ↑ Lee SW, Lee PH, Ahn JM, Park DW, Yun SC, Han S, Kang H, Kang SJ, Kim YH, Lee CW, Park SW, Hur SH, Rha SW, Her SH, Choi SW, Lee BK, Lee NH, Lee JY, Cheong SS, Kim MH, Ahn YK, Lim SW, Lee SG, Hiremath S, Santoso T, Udayachalerm W, Cheng JJ, Cohen DJ, Muramatsu T, Tsuchikane E, Asakura Y, Park SJ (2019). "Randomized Trial Evaluating Percutaneous Coronary Intervention for the Treatment of Chronic Total Occlusion: The DECISION-CTO Trial". Circulation. 139 (14): 1674–83. doi:10.1161/CIRCULATIONAHA.118.031313. Unknown parameter |month= ignored (help); |access-date= requires |url= (help)
  11. ↑ Henriques JPS, Hoebers LP, Råmunddal T, Laanmets P, Eriksen E, Bax M, Ioanes D, Suttorp MJ, Strauss BH, Barbato E, Nijveldt R, van Rossum AC, Marques KM, Elias J, van Dongen IM, Claessen BEPM, Tijssen JGP, van der Schaaf RJ (2016). "Percutaneous Intervention for Concurrent Chronic Total Occlusions in Patients With STEMI: The EXPLORE Trial". Journal of the American College of Cardiology. 68 (15): 1622–32. doi:10.1016/j.jacc.2016.07.744. Unknown parameter |month= ignored (help); |access-date= requires |url= (help)
  12. ↑ Will M, Schwarz K, Aufhauser S, Leibundgut G, Schmidt E, Mayer D, Weiss TW, Huber K, Kammler J, Kellermair J, Blessberger H, Steinwender C, Gschwandtner M, Hamzaraj K, Frick M (2024). "The impact of successful chronic total occlusion percutaneous coronary intervention on clinical outcomes: a tertiary single-center analysis". Frontiers in Cardiovascular Medicine. 11: 1447829. doi:10.3389/fcvm.2024.1447829. Unknown parameter |month= ignored (help); |access-date= requires |url= (help)
  13. ↑ 13.0 13.1 13.2 13.3 13.4 13.5 13.6 Wu EB, Brilakis ES, Mashayekhi K, Tsuchikane E, Alaswad K, Araya M, Avran A, Azzalini L, Babunashvili AM, Bayani B, Behnes M, Bhindi R, Boudou N, Boukhris M, Bozinovic NZ, Bryniarski L, Bufe A, Buller CE, Burke MN, Buttner A, Cardoso P, Carlino M, Chen JY, Christiansen EH, Colombo A, Croce K, de los Santos FD, de Martini T, Dens J, di Mario C, Dou K, Egred M, Elbarouni B, ElGuindy AM, Escaned J, Furkalo S, Gagnor A, Galassi AR, Garbo R, Gasparini G, Ge J, Ge L, Goel PK, Goktekin O, Gonzalo N, Grancini L, Hall A, Hanna Quesada FL, Hanratty C, Harb S, Harding SA, Hatem R, Henriques JPS, Hildick-Smith D, Hill JM, Hoye A, Jaber W, Jaffer FA, Jang Y, Jussila R, Kalnins A, Kalyanasundaram A, Kandzari DE, Kao HL, Karmpaliotis D, Kassem HH, Khatri J, Knaapen P, Kornowski R, Krestyaninov O, Kumar AVG, Lamelas PM, Lee SW, Lefevre T, Leung R, Li Y, Lim ST, Lo S, Lombardi W, Maran A, McEntegart M, Moses J, Munawar M, Navarro A, Ngo HM, Nicholson W, Oksnes A, Olivecrona GK, Padilla L, Patel M, Pershad A, Postu M, Qian J, Quadros A, Rafeh NA, Ramundal T, Rao VSP, Reifart N, Riley RF, Rinfret S, Saghatelyan M, Sianos G, Smith E, Spaedy A, Spratt J, Stone G, Strange JW, Tammam KO, Thompson CA, Toma A, Tremmel JA, Trinidad RS, Ungi I, Vo M, Vu VH, Walsh S, Werner G, Wojcik J, Wollmuth J, Xu B, Yamane M, Ybarra LF, Yeh RW, Zhang Q (2021). "Global Chronic Total Occlusion Crossing Algorithm: JACC State-of-the-Art Review". Journal of the American College of Cardiology. 78 (8): 840–53. doi:10.1016/j.jacc.2021.05.055. Unknown parameter |month= ignored (help); |access-date= requires |url= (help)
  14. ↑ 14.00 14.01 14.02 14.03 14.04 14.05 14.06 14.07 14.08 14.09 14.10 14.11 14.12 14.13 Al-Ogaili A, Brilakis ES (2025). "Insights into the Global Total Occlusion Crossing Algorithm". Interventional Cardiology: Reviews, Research, Resources. 20: e06. doi:10.15420/icr.2024.05. Unknown parameter |month= ignored (help); |access-date= requires |url= (help)
  15. ↑ Werner GS, Ferrari M, Heinke S, Kuethe F, Surber R, Richartz BM, Figulla HR (2003). "Angiographic Assessment of Collateral Connections in Comparison With Invasively Determined Collateral Function in Chronic Coronary Occlusions". Circulation. 107 (15): 1972–7. doi:10.1161/01.CIR.0000061953.72662.3A. Unknown parameter |month= ignored (help); |access-date= requires |url= (help)
  16. ↑ Morino Y, Abe M, Morimoto T, Kimura T, Hayashi Y, Muramatsu T, Ochiai M, Noguchi Y, Kato K, Shibata Y, Hiasa Y, Doi O, Yamashita T, Morimoto T, Hinohara T, Mitsudo K (2011). "Predicting Successful Guidewire Crossing Through Chronic Total Occlusion of Native Coronary Lesions Within 30 Minutes: The J-CTO (Multicenter CTO Registry in Japan) Score as a Difficulty Grading and Time Assessment Tool". JACC. Cardiovascular Interventions. 4 (2): 213–21. doi:10.1016/j.jcin.2010.09.024. Unknown parameter |month= ignored (help); |access-date= requires |url= (help)
  17. ↑ Szijgyarto Z, Rampat R, Werner GS, Ho C, Reifart N, Lefevre T, Louvard Y, Avran A, Kambis M, Buettner HJ, Di Mario C, Gershlick A, Escaned J, Sianos G, Galassi A, Garbo R, Goktekin O, Meyer-Gessner M, Lauer B, Elhadad S, Bufe A, Boudou N, Sinha AK, Hildick-Smith D (2019). "Derivation and Validation of a Chronic Total Coronary Occlusion Intervention Procedural Success Score From the 20,000-Patient EuroCTO Registry: The EuroCTO (CASTLE) Score". JACC. Cardiovascular Interventions. 12 (4): 335–42. doi:10.1016/j.jcin.2018.11.020. Unknown parameter |month= ignored (help); |access-date= requires |url= (help)
  18. ↑ Karacsonyi J, Stanberry L, Alaswad K, Krestyaninov O, Choi JW, Rangan BV, Doing AH, Dattilo P, Toma C, Uretsky BF, Moses JW, Lembo NJ, Parikh M, Kirtane AJ, Ali ZA, Karmpaliotis D, Masoumi A, Khatri JJ, Jaffer FA, Koutouzis M, Tsiafoutis I, Jaber W, Samady H, Sheikh AM, Elbarouni B, Nicholson W, Patel M, Mahmud E, Garcia S, Burke MN, Brilakis ES (2021). "Predicting Technical Success of Chronic Total Occlusion Percutaneous Coronary Intervention: Comparison of 3 Scores". Circulation: Cardiovascular Interventions. 14 (1): e009860. doi:10.1161/CIRCINTERVENTIONS.120.009860. Unknown parameter |month= ignored (help); |access-date= requires |url= (help)
  19. ↑ Azzalini L, Karmpaliotis D, Santiago R, Mashayekhi K, Di Mario C, Rinfret S, Nicholson WJ, Carlino M, Yamane M, Tsuchikane E, Brilakis ES (2022). "Contemporary Issues in Chronic Total Occlusion Percutaneous Coronary Intervention". JACC. Cardiovascular Interventions. 15 (1): 1–21. doi:10.1016/j.jcin.2021.09.027. Unknown parameter |month= ignored (help); |access-date= requires |url= (help)
  20. ↑ Danek BA, Karatasakis A, Karmpaliotis D, Alaswad K, Yeh RW, Jaffer FA, Wyman RM, Lombardi WL, Grantham JA, Kandzari DE, Lembo NJ, Doing A, Toma C, Moses JW, Kirtane A, Parikh M, Ali ZA, Garcia S, Karacsonyi J, Rangan BV, Thompson CA, Banerjee S, Brilakis ES (2016). "Development and Validation of a Scoring System for Predicting Periprocedural Complications During Percutaneous Coronary Interventions of Chronic Total Occlusions: The Prospective Global Registry for the Study of Chronic Total Occlusion Intervention (PROGRESS CTO) Complications Score". Journal of the American Heart Association. 5 (10): e004272. doi:10.1161/JAHA.116.004272. Unknown parameter |month= ignored (help); |access-date= requires |url= (help)
  21. ↑ Vadalà G, Mashayekhi K, Boukhris M, Behnes M, Pyxaras S, Christiansen EH, Bufe A, Gasparini GL, Avran A, Garbo R, Ladwiniec A, Agostoni P, Rathore S, Sianos G, Werner GS, Di Mario C, Galassi AR (2024). "Reclassification of CTO Crossing Strategies in the ERCTO Registry According to the CTO-ARC Consensus Recommendations". JACC. Cardiovascular Interventions. 17 (20): 2425–37. doi:10.1016/j.jcin.2024.09.002. PMID 39477646 Check |pmid= value (help). Unknown parameter |month= ignored (help); |access-date= requires |url= (help)
  22. ↑ Hong SJ, Kim BK, Cho I, Kim HY, Rha SW, Lee SH, Park SM, Kim YH, Chang HJ, Ahn CM, Kim JS, Ko YG, Choi D, Jang Y, Hong MK (2021). "Effect of Coronary CTA on Chronic Total Occlusion Percutaneous Coronary Intervention: A Randomized Trial". JACC. Cardiovascular Imaging. 14 (10): 1993–2004. doi:10.1016/j.jcmg.2021.04.013. Unknown parameter |month= ignored (help); |access-date= requires |url= (help)
  23. ↑ Andreini D, Collet C, Leipsic J, Nieman K, Bittencurt M, De Mey J, Buls N, Mushtaq S, Conte E, Bartorelli AL, Stefanini G, Sonck J, Knaapen P, Ghoshhajra B, Serruys P, Pontone G (2022). "Pre-procedural planning of coronary revascularization by cardiac computed tomography: An expert consensus document of the Society of Cardiovascular Computed Tomography". Journal of Cardiovascular Computed Tomography. 16 (6): 558–72. doi:10.1016/j.jcct.2022.08.003. PMID 36008263 Check |pmid= value (help). Unknown parameter |month= ignored (help); |access-date= requires |url= (help)
  24. ↑ Sandoval Y, Carvalho P, Cheng V, Cavalcante J, Azzalini L, Jalli S, Burke MN, Brilakis ES (2025). "Artificial Intelligence Enhanced Analysis of Coronary CT Angiography to Facilitate Chronic Total Occlusion Percutaneous Coronary Intervention". Catheterization and Cardiovascular Interventions. 107 (1): 395–406. doi:10.1002/ccd.70312. Unknown parameter |month= ignored (help); |access-date= requires |url= (help)
  25. ↑ 25.0 25.1 25.2 25.3 Vadalà G, Galassi AR, Werner GS, Sianos G, Boudou N, Garbo R, Maniscalco L, Bufe A, Avran A, Gasparini GL, La Scala E, Ladwiniec A, Saghatelyan M, Goktekin O, Gorgulu S, Reifart N, Agostoni P, Rathore S, Ayoub M, Behnes M, Atmowihardjo I, Iannaccone M, Diletti R, Di Mario C, Mashayekhi K (2024). "Contemporary outcomes of chronic total occlusion percutaneous coronary intervention in Europe: the ERCTO registry". EuroIntervention. 20 (3): e185–e197. doi:10.4244/EIJ-D-23-00490. PMID 38343371 Check |pmid= value (help). Unknown parameter |month= ignored (help); |access-date= requires |url= (help)
  26. ↑ 26.0 26.1 26.2 26.3 26.4 "Chapter 9: Retrograde Chronic Total Occlusion Interventions — Coronary Interventions Handbook" (PDF). American College of Cardiology. Retrieved 2026-09-16.
  27. ↑ 27.0 27.1 27.2 Allana SS, Kostantinis S, Rempakos A, Simsek B, Karacsonyi J, Alexandrou M, Mutlu D, Choi JW, Poommipanit P, Gorgulu S, Jaffer FA, Chandwaney R, Jaber WA, Nicholson W, Khatri JJ, Krestyaninov O, Khelimskii D, Davies R, Goktekin O, Rangan BV, Mastrodemos OC, Sandoval Y, Burke MN, Brilakis ES (2023). "The Retrograde Approach to Chronic Total Occlusion Percutaneous Coronary Interventions: Technical Analysis and Procedural Outcomes". JACC. Cardiovascular Interventions. 16 (22): 2748–62. doi:10.1016/j.jcin.2023.08.031. PMID 38030360 Check |pmid= value (help). Unknown parameter |month= ignored (help); |access-date= requires |url= (help)
  28. ↑ 28.0 28.1 28.2 Natarajan R, Corballis N, Merinopoulos I, Tsampasian V, Vassiliou VS, Eccleshall SC (2025). "A systematic review and meta-analysis of the use of drug-coated balloon angioplasty for treatment of both de novo and in-stent coronary chronic total occlusions". Clinical Research in Cardiology. 115 (1): 33–47. doi:10.1007/s00392-025-02639-y. PMID 40210772 Check |pmid= value (help). Unknown parameter |month= ignored (help); |access-date= requires |url= (help)
  29. ↑ 29.0 29.1 29.2 29.3 29.4 29.5 29.6 Xenogiannis I, Varlamos C, Benetou DR, Alexopoulos D (2021). "Antithrombotic Therapy in Chronic Total Occlusion Interventions". US Cardiology Review. 15: e10. doi:10.15420/usc.2020.37. Unknown parameter |month= ignored (help); |access-date= requires |url= (help)
  30. ↑ Riley RF, Henry TD, Mahmud E, Kirtane AJ, Brilakis ES, Goyal A, Grines CL, Lombardi WL, Maran A, Rab T, Tannenbaum M, Truesdell AG, Yeh RW, Zhao DX (2020). "SCAI position statement on optimal percutaneous coronary interventional therapy for complex coronary artery disease". Catheterization and Cardiovascular Interventions. 96 (2): 346–62. doi:10.1002/ccd.28994. Unknown parameter |month= ignored (help); |access-date= requires |url= (help)
  31. ↑ Naidu SS, Abbott JD, Bagai J, Blankenship J, Garcia S, Iqbal SN, Kaul P, Khuddus MA, Kirkwood L, Manoukian SV, Patel MR, Skelding KA, Slotwiner D, Swaminathan RV, Welt FG (2021). "SCAI expert consensus update on best practices in the cardiac catheterization laboratory". Catheterization and Cardiovascular Interventions. 98 (2): 255–76. doi:10.1002/ccd.29744. Unknown parameter |month= ignored (help); |access-date= requires |url= (help)
  32. ↑ Olivari Z, Rubartelli P, Piscione F, Ettori F, Fontanelli A, Salemme L, Giachero C, Di Mario C, Gabrielli G, Spedicato L, Bedogni F (2003). "Immediate results and one-year clinical outcome after percutaneous coronary interventions in chronic total occlusions: data from a multicenter, prospective, observational study (TOAST-GISE)". Journal of the American College of Cardiology. 41 (10): 1672–8. PMID 12767645. Unknown parameter |month= ignored (help); |access-date= requires |url= (help)
  33. ↑ Suero JA, Marso SP, Jones PG, Laster SB, Huber KC, Giorgi LV, Johnson WL, Rutherford BD (2001). "Procedural outcomes and long-term survival among patients undergoing percutaneous coronary intervention of a chronic total occlusion in native coronary arteries: a 20-year experience". Journal of the American College of Cardiology. 38 (2): 409–14. PMID 11499731. Unknown parameter |month= ignored (help); |access-date= requires |url= (help)
  34. ↑ de Labriolle A, Bonello L, Roy P, Lemesle G, Steinberg DH, Xue Z, Kaneshige K, Suddath WO, Satler LF, Kent KM, Pichard AD, Lindsay J, Waksman R (2008). "Comparison of safety, efficacy, and outcome of successful versus unsuccessful percutaneous coronary intervention in "true" chronic total occlusions". The American Journal of Cardiology. 102 (9): 1175–81. doi:10.1016/j.amjcard.2008.06.059. PMID 18940287. Unknown parameter |month= ignored (help); |access-date= requires |url= (help)
  35. ↑ Rathore S, Matsuo H, Terashima M, Kinoshita Y, Kimura M, Tsuchikane E, Nasu K, Ehara M, Asakura Y, Katoh O, Suzuki T (2009). "Procedural and in-hospital outcomes after percutaneous coronary intervention for chronic total occlusions of coronary arteries 2002 to 2008: impact of novel guidewire techniques". JACC. Cardiovascular Interventions. 2 (6): 489–97. doi:10.1016/j.jcin.2009.04.008. PMID 19539251. Unknown parameter |month= ignored (help); |access-date= requires |url= (help)
  36. ↑ Stone GW, Reifart NJ, Moussa I, Hoye A, Cox DA, Colombo A, Baim DS, Teirstein PS, Strauss BH, Selmon M, Mintz GS, Katoh O, Mitsudo K, Suzuki T, Tamai H, Grube E, Cannon LA, Kandzari DE, Reisman M, Schwartz RS, Bailey S, Dangas G, Mehran R, Abizaid A, Moses JW, Leon MB, Serruys PW (2005). "Percutaneous recanalization of chronically occluded coronary arteries: a consensus document: part II". Circulation. 112 (16): 2530–7. doi:10.1161/CIRCULATIONAHA.105.583716. PMID 16230504. Unknown parameter |month= ignored (help); |access-date= requires |url= (help)
  37. ↑ 37.0 37.1 37.2 Hirai T, Nicholson WJ, Sapontis J, Salisbury AC, Marso SP, Lombardi W, Karmpaliotis D, Moses J, Pershad A, Wyman RM, Spaedy A, Cook S, Doshi P, Federici R, Nugent K, Gosch KL, Spertus JA, Grantham JA (2019). "A Detailed Analysis of Perforations During Chronic Total Occlusion Angioplasty". JACC. Cardiovascular Interventions. 12 (19): 1902–12. doi:10.1016/j.jcin.2019.05.024. PMID 31255554. Unknown parameter |month= ignored (help); |access-date= requires |url= (help)

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