Advances in the management of coronary chronic total occlusions.

Brilakis, Emmanouil S; Karmpaliotis, Dimitri; Vo, Minh N; Garcia, Santiago; Michalis, Lampros; Alaswad, Khaldoon; Doshi, Parag; Lombardi, William L; Banerjee, Subhash

Chronic total occlusions (CTOs) have been called "the last frontier" of percutaneous coronary intervention (PCI) due to traditionally low success rates and high risk for restenosis and re-occlusion. Recent advances in equipment and crossing techniques have significantly increased CTO PCI success rates while maintaining low risk of complications. Specifically, the retrograde approach and controlled antegrade dissection and re-entry in conjunction with advanced guidewires and microcatheters have significantly improved procedural success rates. Moreover, the introduction of the "hybrid" approach has created a unified framework for operators to approach CTOs in a systematic and efficient fashion. Finally, drug-eluting stents, especially second generation, have improved long-term patency after CTO PCI.