Contemporary Issues in Chronic Total Occlusion Percutaneous Coronary Intervention

Remarkable progress has been achieved in chronic total occlusion (CTO) percutaneous coronary intervention (PCI) in recent years, with refinement of the indications and technical aspects of the procedure, imaging, and complication management. Randomized controlled trials and rigorous prospective registries have provided high-quality data on the benefits and risks of CTO PCI. Global collaboration has led to an agreement on nomenclature, indications, endpoint definition, and principles of clinical trial design that have been distilled in global consensus documents such as the CTO Academic Research Consortium. Increased use of preprocedural coronary computed tomography angiography and intraprocedural intravascular imaging, as well as development of novel techniques and structured CTO crossing and complication management algorithms, allow a systematic, stepwise approach to this difficult lesion subset. This state-of-the-art review provides a comprehensive discussion about the most recent developments in the indications, preprocedural planning, technical aspects, complication management, and future directions of CTO PCI. • The main indication of CTO PCI is symptom relief. • Meticulous pre-procedural planning and systematic crossing attempts are recommended to optimize CTO PCI success rates. • Intravascular imaging can facilitate CTO recanalization and improve long-term outcomes. • A systematic approach to complications can minimize their adverse impact.