Application of the Hybrid Approach to Chronic Total Coronary Occlusion Percutaneous Coronary Intervention

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SUMMARY Percutaneous coronary intervention (PCI) for chronic total occlusion (CTO) continues to evolve constantly with developing equipment and techniques. The hybrid approach to CTO PCI advocates dual coronary injection, careful and structured review of the angiogram, and flexibility. Use of all crossing strategies [antegrade wire escalation, antegrade dissection re-entry and retrograde approach] is encouraged, with initial and subsequent choices influenced by the CTO anatomic characteristics and the outcomes of the originally selected approach. Application of the hybrid approach to CTO PCI has been associated with good outcomes in US and European registries, although CTO PCI outcomes in non-selected populations have been less optimal with approximately 60% success rate. We analyzed the clinical, angiographic, and procedural characteristics of 3,122 CTO PCIs performed in 3,055 patients to determine the techniques and outcomes of hybrid CTO PCI in a diverse group of patients and operators in two continents (at eighteen US, one European, and one Russian centers ) enrolled in the PROGRESS-CTO (PROspective Global REgiStry for the Study of Chronic Total Occlusion Intervention, NCT02061436) registry between January 2012 and November 2017. Technical success rate was 87% and the risk for in-hospital major complications was 3%, providing important benchmarks to use when discussing with patients and providers the risk/benefit ratio of CTO PCI. The final successful crossing strategy was antegrade wire escalation in 52%, retrograde in 27%, and antegrade dissection reentry in 21%; more than 1 crossing strategies were required in 41% of the cases. CTO PCI is currently being performed with high success and acceptable complication rates among various experienced centers in the US and Europe. Bridging the gap between what is currently achieved and what can be achieved in chronic total occlusion intervention should be a major focus of upcoming research and education efforts.

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