Author + information
- Received March 27, 2017
- Revision received June 12, 2017
- Accepted June 29, 2017
- Published online November 6, 2017.
- Scott A. Harding, MDa,∗ (, )
- Eugene B. Wu, MDb,
- Sidney Lo, MBBSc,
- Soo Teik Lim, MDd,
- Lei Ge, MDe,
- Ji-Yan Chen, MDf,
- Jie Quan, MDg,
- Seung-Whan Lee, MD, PhDh,
- Hsien-Li Kao, MDi and
- Etsuo Tsuchikane, MD, PhDj
- aDepartment of Cardiology, Wellington Hospital, Wellington, New Zealand
- bPrince of Wales Hospital, Hong Kong
- cLiverpool Hospital, Sydney, Australia
- dNational Heart Centre, Singapore
- eShanghai Zhongshan Hospital, Shanghai, China
- fGuangdong General Hospital, Guangdong, China
- gBeijing Fuwai Hospital, Beijing, China
- hDepartment of Cardiology, Asan Medical Center, University of Ulsan, Seoul, Republic of Korea
- iDepartment of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
- jToyohashi Heart Centre, Toyohashi, Aichi, Japan
- ↵∗Address for correspondence:
Dr. Scott A. Harding, Department of Cardiology, Wellington Hospital, Private Bag 7902, Wellington South, New Zealand.
Although the hybrid chronic total occlusion (CTO) algorithm had many excellent recommendations, there has been infrequent adoption in the Asia Pacific region. The Asia Pacific CTO club propose an algorithm for case selection based on the Japan-CTO score and a new CTO algorithm, which is applicable globally. This algorithm allows for differing skill sets and equipment availability and contains practical teaching for CTO percutaneous coronary intervention. Similar to the hybrid algorithm there are 3 main questions that determine whether the primary approach is antegrade or retrograde: 1) is there proximal cap ambiguity; 2) is the distal vessel of poor quality; and 3) are there interventional collaterals present. In contrast to the hybrid algorithm occlusion length alone does not determine the choice of either a wire escalation strategy or a dissection re-entry strategy. Rather a combination of factors including ambiguity of the vessel course, severe calcification, tortuosity, length, and previous failure are used to determine this. The role of intravascular ultrasound–guided entry to overcome proximal cap ambiguity and the CrossBoss catheter in occlusive in-stent restenosis are highlighted in the algorithm. Both the parallel wire technique and dissection re-entry with the Stingray system have been included as options when the initial antegrade wire passage fails. Intravascular ultrasound–guided wiring along with limited subintimal tracking and re-entry are included as final options in the algorithm. Finally, the algorithm incorporates guidance on when to stop the procedure. It is hoped that this algorithm will serve as the basis for future CTO percutaneous coronary intervention proctoring and training.
Dr. Harding has received speaking and consultancy fees from Boston Scientific, Medtronic, Bio-Excel, and Asahi Intecc. Dr. Wu has received proctoring fees from Boston Scientific; and has stock ownership in Abbott and Medtronic. Dr. Lo has received speaking and proctoring honoraria from Bio-Excel. Dr. Lim has received research grant/travel support or speaker honorarium from Orbus Neich, Asahi Intecc, Terumo, Biosensors, Biotronik, Abbott Vascular, Aluimedica, Boston Scientific, and Keneka. Dr. Tsuchikane is a consultant for Boston Scientific, Asahi Intecc, and Nipro. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received March 27, 2017.
- Revision received June 12, 2017.
- Accepted June 29, 2017.
- 2017 American College of Cardiology Foundation
- Graphical abstract
- Japan-CTO Score, Case Selection, and Proctoring
- The Main Algorithm
- Anatomic Analysis
- In-Stent Restenosis
- IVUS Guidance to Overcome Proximal Cap Ambiguity
- Antegrade Preparation First Philosophy
- Antegrade Wire Escalation
- When to Knuckle Wire
- Parallel Wiring Versus Antegrade Dissection Re-Entry
- Retrograde Subalgorithm
- When to Stop