Opening the chronically occluded coronary(CTO) artery gives the ultimate sense of achievement and satisfaction for the cardiologist. Of course , the patient may or may not share the same feeling . . . ! There are simple and complex CTOs . Some CTOs are opened in few minutes , some fail even after hours of manipulation . For successful CTO opening both hardware and technique are equally important.
Now we understand , acquiring expertise with one or two guidewires and mastering them is the key to success. Frequent changing of guidewires and other hardware has increased the complication.
Definition of success in CTO
Unfortunately cardiologists have varied perception on this vital issue . Most believe opening a CTO is synonymous with success . Some perceive even crossing a CTO with a guidewire is a partial success ! Real success lies in providing sustained opening and restoring flow till the micro circulatory level. Advancing the distal blood flow for a short distance at a low velocity can not be termed a success . It must be ensured all the branches of opened coronary artery must be perfused . This is a tricky issue as we can only guess the number of branches it had , before getting occluded.
The other most important factor in determining the success of CTO opening is the status of distal microcirculation . A dead myocardium does not welcome the blood flow ! .It simply rejects it and this results in lower grades of TIMI flow. This factor is mainly responsible for the negative clinical outcome of major PCI trials( TOAT, COURAGE)
The newer devices are helping us to achieve our goal .
- Retrograde approach through collaterals
- Sub initmal tracking of CTOs
- Japanese have pioneered the CTO interventions
http://www.flowcardia.com/index1.html
Dr.S.Venkatesan MD 
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