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| Basic Wire-Handling Strategies for Chronic Total Occlusions | 1/10
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Fifteen years have passed since the first Interventional procedures to treat chronic total occlusions (CTO's). In all that time no new device has emerged to revolutionize the field in the way that has happened in other areas of Coronary Intervention. The emergence of stents, the rotablator and DCA has meant that patients, for whom treatment would previously have ended without optimal dilatation, are now receiving optimal results and reduced reocclusion rates.
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| Figure 1: Acute success rates
~ change over time The figures shown are the author's own results, with initial success rates passing 80% in 1992, rising even further, and since 1993 stabilising at around 85%. |
The most important thing in revascularizing CTO's is how to get the wire across the occlusion. In this sense, the lack of a revolutionary new device for CTOs means that strategy depends to a large extent on the experience, expertise and instincts of the operator and requires a considerable amount of precise and delicate work. This is not to say that experience and instinct are everything in Intervention for CTOs, as the breadth of the cardiologist's knowledge and the strategy selected are also vitally important. One very important development has been the availability, since the early 1990s of wires offering greater control of the wire tip inside the lesion. Because better wires have allowed the crossing of more lesions, newer PTCA modalities can now be applied to CTOs that could never be crossed in the past. Along with improved wire control improved operator expertise has contributed to rapidly rising success rates (Figure 1).
In this text, I set out, as specifically as possible, the basics of interventional strategy for CTOs. It has been said that wire handling is everything in Intervention for CTOs, but in order to get the best from a wire, it is of critical importance to evaluate the lesion before Intervention and identify the most suitable approach. It is equally important to choose the best treatment option once the lesion has been assessed and the wire passed across it.
I also want to stress that physicians attempting Intervention for CTOs often make the mistake of thinking that the procedure depends solely on their own sensitivity to what the wire is doing. This is not the case. What differentiates CTO's from other lesions, is that CTO procedures require endless delicacy and patience, even if the simplest available strategy will often be the best treatment option. Another difference is that one cannot expect anything near a 100% success rate with CTOs, and should always be prepared for the unexpected. For that reason, a clear strategy is vital, and merely leaving it to touch, or sticking rigidly to a specific approach leaves the physician relying too much on luck, and not basing strategy for a better and more certain acute result on the sophistication of the available technology. The main point is that the best way to increase chances of success is to adapt a strategy tailored to the conditions.
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