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Chronic Total Occlusion Angioplasty in the United States

J. Aaron Grantham, MD^_*,_*, Steven P. Marso, MD^_*, John Spertus, MD, MPH^_*, John House, MS^_*, David R. Holmes, Jr, MD, Barry D. Rutherford, MD^_*

^_* Saint Luke's Health System's Mid-America Heart Institute, University of Missouri Kansas City School of Medicine, Kansas City, Missouri
Mayo Graduate School of Medicine, Mayo Clinic, Rochester, Minnesota

^_* Reprint requests and correspondence: Dr. J. Aaron Grantham, Clinical Associate Professor of Medicine, University of Missouri Kansas City, 4401 Wornall Road, MAHI-5426, Kansas City, Missouri 64111 (Email: jgrantham{at}cc-pc.com).

Coronary chronic total occlusions (CTOs) are commonly encountered complex lesions identified in 15% of all patients referred for coronary angiography. Chronic total occlusion remains the most powerful predictor of referral for coronary bypass surgery. The benefits of CTO percutaneous coronary intervention (PCI) include symptom relief, improved left ventricular function, and potentially a survival advantage associated with success when compared with failed CTO-PCI. Data from the NCDR (National Cardiovascular Data Registry) suggest that CTO-PCI attempt rates in the U.S. have not changed over the past 5 years despite significant advances in techniques and technology, some of which we review here. Additionally, these data highlight a major disparity in attempt rates based on operator PCI volume. Remaining barriers to attempting CTO-PCI in the U.S. include operator inexperience, the perception of increased risk of CTO-PCI, and financial disincentives to operators and hospitals. To overcome operator inexperience, participation in CTO clubs, the invitation of guest operators, and a dedicated CTO day can be implemented at institutions committed to learning advanced CTO-PCI techniques so that operators can overcome the barriers and offer patients access to percutaneous therapy when it is clinically indicated.

Key Words: coronary artery disease • chronic total occlusion • angioplasty

Abbreviations and Acronyms   CART = controlled antegrade and retrograde tracking   CTO = chronic total occlusion   MI = myocardial infarction   NCDR = National Cardiovascular Data Registry   PCI = percutaneous coronary intervention

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