Percutaneous Coronary Interventions for Chronic Total Occlusions
As the Technology Expands, Our Responsibilities Increase
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Opposing Viewpoint, see p 1382
“To a man with a hammer, the world looks like a nail.”
The continuing evolution of new technologies has resulted in a noted improvement in procedural outcomes in patients undergoing percutaneous coronary interventions (PCI) for chronic total occlusions (CTO). We now have an expansive selection of interventional tools and techniques to successfully perform these complex interventional procedures. Coronary guide wires specifically engineered to facilitate crossing almost any CTO lesion are now available. We have developed plaque modification tools, devices facilitating directed subintimal tracking and reentry, and retrograde CTO techniques resulting in previously unimagined procedural success rates approaching >80% in the hands of experienced operators. These tools have allowed us to expand the group of patients that we now consider approachable, although CTO PCI currently represent only 3% to 4% of all PCI procedures performed in the United States.1 Similarly, procedural complication rates continue to decline, although other factors such as radiation exposure, contrast volume, and the increased use of costly resources remain problematic. Overall, these observations underscore the need for the cardiac interventional community to more objectively understand the risks and benefits of CTO PCI.
CTO PCI and Mortality Benefit
Although a possible mortality benefit for most patient populations undergoing PCI has been extensively investigated, a clear mortality benefit has only been clearly demonstrated in patients presenting with acute coronary syndromes, …