Changing the focus in Chronic Total Occlusions:- Revascularisation based on need rather than anatomy

Abstract

Percutaneous coronary intervention (PCI) for chronic total occlusions (CTO) has previously been limited by the technical difficulty of revascularization [1-2]. This has led to case selection, where revascularisation attempts have often been based on angiographic features and the presence of suitable anatomy. Scoring systems have been developed which have demonstrated that more complex lesions are more difficult to revascularise. This has led to the myth of CTO success rates approximating at 70% of attempts [3-4]. These success rates were not initially replicated by randomised data [5], but were maintained by case selection, where attempts at revascularisation were primarily confined to less complex lesions. The physiological imperative for revascularisation seemed a secondary concern to feasibility. However, as with non-CTO interventions the decision to attempt CTO revascularisation should predominantly be based on clinical indications including the presence of angina, the degree of ischaemia and viability in the territory supplied by the occluded vessel [6].