JACC: CARDIOVASCULAR INTERVENTIONS VOL. 10, NO.

21, 2017

ª 2017 BY THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION ISSN 1936-8798/$36.00

PUBLISHED BY ELSEVIER http://dx.doi.org/10.1016/j.jcin.2017.06.071

STATE-OF-THE-ART REVIEW

A New Algorithm for Crossing Chronic

Total Occlusions From the Asia Pacific
Chronic Total Occlusion Club
Scott A. Harding, MD,a Eugene B. Wu, MD,b Sidney Lo, MBBS,c Soo Teik Lim, MD,d Lei Ge, MD,e Ji-Yan Chen, MD,f
Jie Quan, MD,g Seung-Whan Lee, MD, PHD,h Hsien-Li Kao, MD,i Etsuo Tsuchikane, MD, PHDj

ABSTRACT

Although the hybrid chronic total occlusion (CTO) algorithm had many excellent recommendations, there has been
infrequent adoption in the Asia Pacific region. The Asia Pacific CTO club propose an algorithm for case selection based
on the Japan-CTO score and a new CTO algorithm, which is applicable globally. This algorithm allows for differing skill
sets and equipment availability and contains practical teaching for CTO percutaneous coronary intervention. Similar to
the hybrid algorithm there are 3 main questions that determine whether the primary approach is antegrade
or retrograde: 1) is there proximal cap ambiguity; 2) is the distal vessel of poor quality; and 3) are there interventional
collaterals present. In contrast to the hybrid algorithm occlusion length alone does not determine the choice of either
a wire escalation strategy or a dissection re-entry strategy. Rather a combination of factors including ambiguity of
the vessel course, severe calcification, tortuosity, length, and previous failure are used to determine this. The role of
intravascular ultrasound–guided entry to overcome proximal cap ambiguity and the CrossBoss catheter in occlusive
in-stent restenosis are highlighted in the algorithm. Both the parallel wire technique and dissection re-entry with the
Stingray system have been included as options when the initial antegrade wire passage fails. Intravascular ultrasound–
guided wiring along with limited subintimal tracking and re-entry are included as final options in the algorithm. Finally,
the algorithm incorporates guidance on when to stop the procedure. It is hoped that this algorithm will serve as the
basis for future CTO percutaneous coronary intervention proctoring and training. (J Am Coll Cardiol Intv 2017;10:2135–
43) © 2017 by the American College of Cardiology Foundation.

C hronic total occlusions (CTO) represent one

of the most challenging lesion subsets in
patients undergoing percutaneous coronary
intervention (PCI). Historically CTO PCI was associ-
ated with significantly lower success rates and
increased adverse events compared with PCI for other
lesion subsets (1). Recently there has been a rapid
and continuous evolution of CTO equipment and
techniques that has driven greater procedural success
and improved clinical outcomes. Despite this, success

From the aDepartment of Cardiology, Wellington Hospital, Wellington, New Zealand; bPrince of Wales Hospital, Hong Kong;
c
Liverpool Hospital, Sydney, Australia; dNational Heart Centre, Singapore; eShanghai Zhongshan Hospital, Shanghai, China;
f
Guangdong General Hospital, Guangdong, China; gBeijing Fuwai Hospital, Beijing, China; hDepartment of Cardiology, Asan
Medical Center, University of Ulsan, Seoul, Republic of Korea; iDepartment of Internal Medicine, National Taiwan University
Hospital, Taipei, Taiwan; and the jToyohashi Heart Centre, Toyohashi, Aichi, Japan. Dr. Harding has received speaking and con-
sultancy fees from Boston Scientific, Medtronic, Bio-Excel, and Asahi Intecc. Dr. Wu has received proctoring fees from Boston
Scientific; and has stock ownership in Abbott and Medtronic. Dr. Lo has received speaking and proctoring honoraria from Bio-Excel.
Dr. Lim has received research grant/travel support or speaker honorarium from Orbus Neich, Asahi Intecc, Terumo, Biosensors,
Biotronik, Abbott Vascular, Aluimedica, Boston Scientific, and Keneka. Dr. Tsuchikane is a consultant for Boston Scientific, Asahi
Intecc, and Nipro. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.

Manuscript received March 27, 2017; revised manuscript received June 12, 2017, accepted June 29, 2017.
2136 Harding et al.
A New Algorithm for CTO Crossing
ABBREVIATIONS rates remain variable (2) with the best
AND ACRONYMS outcomes being reported in centers with
dedicated CTO programs and high-volume
CART = controlled antegrade
and retrograde tracking
CTO operators (3–5).
The landmark work by Brilakis et al. (2)
CCTA = coronary computed
tomography angiography describing a percutaneous treatment algo-
CTO = chronic total occlusion rithm for crossing CTO, now commonly
ISR = in-stent restenosis
referred to as the hybrid algorithm, has
become the basis of discussion and reference
IVUS = intravascular
ultrasound for CTO PCI worldwide. This algorithm
J-CTO = Japan-CTO Score emphasized the importance of dual in-
PCI = percutaneous coronary
jections for CTO PCI angiography, promoted
intervention careful review and a standardized approach
to the evaluation of the coronary angiogram,
used the angiographic characteristics to guide
selection of the initial strategy, and encouraged early
conversion to an alternative crossing strategy if the
initial crossing strategy failed. The algorithm has
been shown to enhance success rates in complex
CTO lesions and to be reproducible and teachable.
The same authors are also to be credited with
executing a remarkable and efficacious proctoring
program that has radically altered the landscape of
CTO intervention in North America and Europe (6–8).
Although there are many excellent recommenda-
tions within the hybrid algorithm, there has been
infrequent adoption of the hybrid algorithm in the Asia
Pacific region where most of the world’s population
resides. This is caused in part by the traditional wire-
based CTO teaching that is dominant in the region,
and limited access to the CrossBoss and Stingray sys-
tem (Boston Scientific, Marlborough, Massachusetts),
which eliminates the antegrade dissection re-entry
arm of the hybrid algorithm. Other factors, such as
lower rates of coronary artery bypass grafting (3,9),
have also likely contributed to the differences in CTO
PCI approaches seen in the Asia Pacific region.
The Asia Pacific CTO club, a group comprised of
10 high-volume CTO operators who are recognized as
leaders in CTO intervention in their respective
countries, was motivated by the hybrid authors to
propose a new algorithm for CTO PCI that would be
relevant and applicable globally. This algorithm
allows for differing skill sets and equipment avail-
ability and contains practical teachings for CTO PCI.
It is hoped that this algorithm will serve as the basis
for future CTO PCI proctoring and training.
JAPAN-CTO SCORE, CASE SELECTION,
AND PROCTORING
Mastering retrograde techniques and the use of the
CrossBoss and Stingray system requires training and
experience. Although these techniques can be taught
JACC: CARDIOVASCULAR INTERVENTIONS VOL. 10, NO. 21, 2017
NOVEMBER 13, 2017:2135–43
it is unlikely that operators will become proficient in
all techniques unless they perform a large volume
(>50 cases per year) of CTO PCI. However, many
skilled PCI operators can perform CTO PCI using
antegrade wire escalation techniques with a high
degree of success if appropriate cases are selected.
We therefore propose an algorithm incorporating the
Japan-CTO (J-CTO) score to guide the selection of
which cases should be attempted by nonexpert CTO
operators and which cases should be referred or
performed with the assistance of a proctor (Figure 1).
The J-CTO score was derived from the J-CTO
(Multicenter CTO Registry of Japan) registry cohort to
predict the probability of successful guidewire
crossing within 30 min and is the most widely
accepted measure of CTO complexity (10). The J-CTO
score is determined by assigning 1 point for each of
the following independent predictors of this
endpoint: blunt entry stump, calcification, bend >45
,
occlusion length >20 mm, and previous failed
attempt. The summation of all points accrued is then
used to stratify lesions into 4 difficulty groups: easy
(J-CTO score of 0), intermediate (score of 1), difficult
(score of 2), and very difficult (score of $3). As the
J-CTO score increases, procedural efficiency and
overall success rates fall (10–13).
In the original study a J-CTO score of $2 was
associated with a <50% chance of successful wire
crossing within 30 min (10). A subsequent study
performed in the United States by hybrid operators
demonstrated that as the J-CTO score increased, the
use of the retrograde approach increased markedly
with the retrograde approach being the successful
approach in 34% of those with a J-CTO score $2
compared with only 5% in those with a J-CTO score
of <2 (13). We therefore recommend that for cases
with a J-CTO score $2, operators relatively early in
their CTO PCI experience or with a limited range of
CTO skills should either seek the assistance of a
proctor or refer the case to a CTO expert. A CTO
expert can be defined as an operator who has
performed at least 200 CTO PCIs, has mastered all the
available techniques, and who can achieve a $85%
success rate in unselected clinically indicated cases.
Proctoring is a powerful tool to improve CTO PCI
skills. Sharma et al. (14) found the impact of
proctoring to be particularly useful in patients with
J-CTO scores of $2 with success rates improving
from 49.5% to 70.7%. We encourage nonexpert CTO
operators to seek proctoring for complex cases
where possible and recommend that all retrograde
and antegrade dissection re-entry cases should be
proctored until the operator has gained competency
in these techniques.
JACC: CARDIOVASCULAR INTERVENTIONS VOL. 10, NO. 21, 2017
NOVEMBER 13, 2017:2135–43
THE MAIN ALGORITHM
The main algorithm (Figure 2) begins with a careful
review of the anatomy (coronary angiogram and
coronary computed tomography angiography [CCTA]
if available). Isolated occlusive in-stent restenosis
(ISR) is separated into a distinct category where it is
recommended that use of a CrossBoss catheter be
considered as the primary crossing strategy.
Similar to the hybrid algorithm there are 3 main
questions that determine whether the primary
approach is antegrade or retrograde: 1) is there prox-
imal cap ambiguity; 2) is the distal vessel of poor
quality; and 3) are there interventional collaterals
present. In contrast to the hybrid algorithm the role
of intravascular ultrasound (IVUS)–guided entry to
overcome proximal cap ambiguity is highlighted
in the main algorithm. In our experience ambiguity of
the proximal cap is relatively common. We believe
IVUS-guided proximal cap entry is an essential skill
for CTO operators to acquire and one that can be
easily taught and that can resolve proximal cap
ambiguity in most cases.
The algorithm also differs from the hybrid
algorithm in that the length of the occlusion alone
does not determine the choice of either a wire
escalation strategy or a dissection re-entry strategy.
We acknowledge that lesion length is an important
determinant of successful lesion crossing when us-
ing a wire escalation strategy wire (10). However,
there are several other important factors including
ambiguity of the vessel course, tortuosity, degree of
calcification, and whether there has been previous
failed wiring attempts that should also be taken
into account when making this decision, which are
highlighted in the main algorithm. The course of
the CTO body is considered ambiguous where there
is a long length of occlusion with no landmarks,
such as calcium, previous stents, or visible channels
to indicate the vessel course, and CCTA has not been
performed.
The use of the parallel wire technique and
IVUS-guided wiring as a last resort has been
included as options in the antegrade arm of the
algorithm. Parallel wiring can be very effective
and not all distal vessels are suitable for re-entry.
The use of antegrade dissection re-entry with the
Stingray System (Boston Scientific) may also be
limited by other factors including availability,
expertise, and cost.
Guidance on when to stop a procedure is also
incorporated into the main algorithm. This and other
aspects of the main algorithm are discussed in more
detail next.
Harding et al. 2137
A New Algorithm for CTO Crossing
F I G U R E 1 Case Selection Guided by the J-CTO Score
This algorithm is designed to help operators with limited or early chronic total occlusion
(CTO) experience with case selection. If the J-CTO Score is $2 then we suggest that for
operators with limited CTO experience it is best to either perform the case with a
proctor or refer the case to an experienced CTO operator. CCTA ¼ coronary computed
tomography angiography; J-CTO ¼ Japan-CTO Score.
ANATOMIC ANALYSIS
Careful analysis of the angiogram is fundamental to
planning the CTO PCI strategy and assessing the risk/
benefit ratio. Dual injections are an essential compo-
nent of CTO PCI and should be performed routinely
except in cases where there are no contralateral
collaterals. Pre-procedural CCTA provides informa-
tion about the vessel course in the occluded segment,
calcification, lesion length, stump morphology,
presence of side branches, and post–coronary artery
bypass grafting anatomy, which may not be apparent
on invasive angiography and may improve procedural
success in complex CTO PCI (15). We recommend that
pre-procedural CTCA be considered in cases with a
high J-CTO score, previous coronary artery bypass
grafting, and previous failure. In general CTO PCI
should be performed as a planned procedure rather
than on an ad hoc basis because this allows time for
careful analysis of the angiogram, calculation of the
J-CTO score, thorough procedural planning, and
informed discussion with the patients.
IN-STENT RESTENOSIS
We recommend that the CrossBoss catheter should be
considered as the first-line device for recanalization
of occlusive ISR because it facilitates rapid crossing of
the ISR segment with high procedural success rates
(16). The advantage of the CrossBoss catheter is that
its blunt rounded tip generally prevents the device
from going underneath stent struts, which results in
either inability to cross with devices or deformation
of the previously placed stent. If there is diffuse
proliferative ISR involving the vessel proximal to the
stent then use of a wire to lead the CrossBoss into
2138 Harding et al. JACC: CARDIOVASCULAR INTERVENTIONS VOL. 10, NO. 21, 2017

A New Algorithm for CTO Crossing NOVEMBER 13, 2017:2135–43

F I G U R E 2 The Main Algorithm for CTO Crossing

The algorithm starts with review of the anatomy using dual-injection angiography  coronary computed tomography angiography. Isolated
occlusive in-stent restenosis is placed into a separate category where use of the CrossBoss is recommended. Three main questions determine
whether the primary approach to crossing the chronic total occlusion is antegrade or retrograde: 1) is there proximal cap ambiguity that cannot
be overcome by intravascular ultrasound; 2) is the distal vessel of poor quality; and 3) are there interventional collaterals present. Length of
the occlusion alone does not determine the choice of either a wire escalation or a dissection re-entry strategy. Rather, several factors are
considered. In most cases the antegrade approach starts with antegrade wire escalation. If this fails parallel wiring, dissection re-entry with
the Stingray System, and the retrograde approach are all included as options. Use of intravascular ultrasound–guided wiring or limited
antegrade subintimal tracking is included as a last resort. Specific guidance is provided regarding when to stop a procedure. eGFR ¼
estimated glomerular filtration rate; IVUS ¼ intravascular ultrasound; KWT ¼ knuckle wire technique; LAST ¼ limited antegrade subintimal
tracking; other abbreviations as in Figure 1.

the stented segment is recommended. Because the preventing progress of the CrossBoss. To overcome
CrossBoss is a blunt dissection tool it often requires this we recommend puncture of the proximal cap
strong backup support to be advanced through the with an intermediate to high penetration force wire
CTO. Occasionally the proximal cap may be very hard and pre-dilation with a small balloon. Once in the ISR
JACC: CARDIOVASCULAR INTERVENTIONS VOL. 10, NO. 21, 2017
NOVEMBER 13, 2017:2135–43
segment, the CrossBoss can be advanced by rapid
spinning until the CrossBoss has either crossed the
CTO or reached the distal stent edge. If the ISR
extends distal to the stent then we recommend using
a wire to access the distal lumen. If the wire cannot
access the distal true lumen after a brief try, the
CrossBoss should be delivered further distally.
The CrossBoss will either enter the distal true lumen
or produce a subintimal space to set up for Stingray
re-entry.
Acute angulation in the stented segment is the
most common reason for failure of the CrossBoss to
pass through occlusive ISR (16). In some of these
cases redirection of the CrossBoss catheter within
the occlusion using a stiff coronary guidewire may
be successful. Other causes of failure include exit of
the CrossBoss into a side branch or the subintimal
space when there is a gap between stents in the
occlusive segment, stent fracture, stent deformation,
or gross stent underdeployment. Therefore, it is
important to review the angiogram closely to identify
such issues.
IVUS GUIDANCE TO OVERCOME
PROXIMAL CAP AMBIGUITY
Proximal cap ambiguity is encountered frequently
and represents a major barrier to a successful ante-
grade approach to CTO PCI. Accurate identification
of the proximal cap is essential to allow safe and
successful antegrade wiring. If ambiguity of the
proximal cap is present we should resolve this using
IVUS guidance. The IVUS catheter should be placed in
the branch closest to the region of the proximal cap
and angiograms in multiple views taken when the
IVUS is located at the proximal cap. Use of an 8-F
guiding catheter is required to accommodate a Corsair
(Asahi Intecc, Nagoya, Japan) and an IVUS catheter at
the same time allowing wiring of the proximal cap
using real-time IVUS guidance. However, use of a
lower-profile microcatheter, such as the Caravel
(Asahi Intecc), allows accommodation of an IVUS
catheter at the same in a 7-F guiding catheter.
In addition, IVUS also provides information regarding
the composition of the cap and can help to guide the
initial wire choice. Occasionally, there may be no
side branch near the cap suitable for IVUS or
IVUS may fail to resolve the ambiguity. In such
cases retrograde wiring up to the proximal cap or
techniques that “move the cap,” such as balloon-
assisted subintimal re-entry or the “scratch-and-go,”
technique can be used to overcome proximal cap
ambiguity and progress the case (17).
Harding et al. 2139
A New Algorithm for CTO Crossing
ANTEGRADE PREPARATION
FIRST PHILOSOPHY
The importance of overcoming proximal cap ambi-
guity with IVUS is part of our “antegrade preparation
first” philosophy. Even if we plan to use retrograde,
antegrade preparation should be performed before-
hand in most cases. The rationale for this is that
antegrade preparation first reduces the time the
retrograde system is engaged and thus reduces
donor artery risk and CTO territory ischemic time
(particularly if the collateral is dominant). It also
encourages going directly to reverse controlled
antegrade retrograde tracking (CART), which is the
most efficient way to attain retrograde wire crossing.
Finally, the antegrade preparation first philosophy
removes the risks of single retrograde wire crossing in
ostial lesions.
ANTEGRADE WIRE ESCALATION
If there is no proximal cap ambiguity or if it can
be resolved by use of IVUS then antegrade wire
escalation is the preferred initial strategy in most
cases. Even if unsuccessful it can serve as preparation
for either antegrade dissection re-entry or a retro-
grade approach and may avoid the need for or reduce
the length of subintimal dissection. However, it is
important not to get “stuck in a failure mode” with
antegrade wiring expending contrast, radiation,
and time with little progress thereby eliminating the
possible use of other strategies.
There are multiple wires on the market that are
promoted for use in CTO PCI and several different
techniques for using these wires including sliding,
intentional intimal tracking, controlled drilling,
penetration, and subintimal tracking. The most
commonly used CTO wires and their properties are
listed in Table 1. We outline a strategy for antegrade
wire escalation (Figure 3) but accept wire choice is
driven by operator familiarity and availability.
Microcatheters should routinely be used in
conjunction with the guidewire as part of CTO PCI
procedures. Microcatheters allow for rapid exchange
of guidewires while maintaining wire position and
improve guidewire torque response. Microcatheters
also improve support and allow the penetration power
of the guidewire to be altered dynamically by chang-
ing the distance between the microcatheter tip and
wire tip. The Corsair and Turnpike (Vascular Solu-
tions, Minneapolis, Minnesota) microcatheters have
good penetration power and are excellent for ante-
grade CTO crossing and retrograde channel crossing.
2140 Harding et al. JACC: CARDIOVASCULAR INTERVENTIONS VOL. 10, NO. 21, 2017

A New Algorithm for CTO Crossing NOVEMBER 13, 2017:2135–43

to have a tougher composition. We recommend use of

T A B L E 1 Guidewires Commonly Used for CTO Crossing
an intermediate penetration force wire as the initial
Polymer Tapered Tip Tip Load wire in combination with a microcatheter with
Wire Category Wire Name Jacket (inch) (gf) Manufacturer
good penetration properties, such as the Corsair
Low penetration force Fielder XT* ✔ 0.009 0.8 Asahi Intecc
or Turnpike in these cases. If penetration is unsuc-
Fielder XT-R* ✔ 0.010 0.6 Asahi Intecc
Fielder XT-A* ✔ 0.010 1.0 Asahi Intecc cessful further escalation to a high penetration force
Pilot 50 ✔ ✕ 1.5 Abbott Vascular guidewire is recommended.
Fighter ✔ 0.009 1.5 Boston Scientific If a high penetration force guidewire has been used
Hornet ✕ 0.008 1.0 Boston Scientific to puncture the proximal cap it is important to step
Gaia 1st ✕ 0.010 1.7 Asahi Intecc down to a lower penetration force wire, unless the
Cross-it 100XT ✕ 0.010 2.0 Abbott Vascular
occlusion is short and the course unambiguous.
Intermediate penetration Pilot 150 ✔ ✕ 2.7 Abbott Vascular
force Stepping down to an intermediate nontapered wire,
Pilot 200* ✔ ✕ 4.1 Abbott Vascular
Gladius ✔ ✕ 3.0 Asahi Intecc
such as the MiracleBros 3 (Asahi Intecc) or Pilot 200,
Miracle 3 ✕ ✕ 3.0 Asahi Intecc reduces the risk of perforation and increases the
Ultimate 3* ✕ ✕ 3.0 Asahi Intecc chance of tracking the vessel.
Gaia 2nd* ✕ 0.010 3.5 Asahi Intecc Once the distal cap is reached it may be necessary
Cross-it 200 ✕ 0.011 3.0 Abbott Vascular to step up to a wire with a higher penetration force to
High penetration force Conquest Pro* ✔ 0.009 9.0 Asahi Intecc
puncture through the distal cap into the distal true
Conquest Pro 12* ✔ 0.009 12.0 Asahi Intecc
lumen. It is very important to control the wire tip
Gaia 3rd* ✕ 0.012 4.5 Asahi Intecc
intentionally to the direction of the distal true lumen
Hornet 10 ✕ 0.008 10.0 Boston Scientific
Hornet 14 ✕ 0.008 14.0 Boston Scientific with examination of the angiogram from several
PROGRESS 200T ✕ 0.009 13.0 Abbott Vascular different angles before attempting to penetrate the
Miracle 12 ✕ ✕ 12.0 Asahi Intecc distal cap.

*Most commonly used guidewires.

WHEN TO KNUCKLE WIRE
CTO ¼ chronic total occlusion.

The knuckle wire has become an important tool in

Angiographic morphology can guide initial guide-
wire choice for proximal cap penetration. If IVUS
interrogation of the proximal cap has been performed
this is also very helpful delineating cap morphology
and can guide guidewire choice. If there is a func-
tional CTO or partial recanalization with visible
channels we recommend starting with a tapered
polymer jacketed wire with a low tip load, such as the
Fielder XT-R (Asahi Intecc). The tapered tip facilitates
entry into the microchannel, the polymer jacket
enhances lubricity and trackability, and the low tip
load reduces the likelihood of the guidewire exiting
the microchannel.
If the proximal cap has a tapered morphology this
often signifies that the occlusion is more recent and
has a softer composition (18). In these cases we
recommend starting with a Fielder XT-A (Asahi
Intecc), or other low penetration force wire. If this is
unsuccessful then escalation to an intermediate
penetration force guidewire, such as the GAIA 2nd
(Asahi Intecc) or Pilot 200 (Abbott Vascular, Santa
Clara, California), and if necessary to a high gram-force
wire with a tapered tip, such as the Conquest Pro or
Conquest Pro 12 (Asahi Intecc), should be undertaken.
It the proximal cap has a blunt morphology this
often signifies that the occlusion is older and is likely
both antegrade and retrograde CTO PCI. The major
benefit of the knuckle wire is that it allows occluded
segments to be negotiated rapidly with a low
perforation risk even in the presence of anatomic
ambiguity. However, as the knuckle tracks the
subintimal space, a mechanism for re-entry into
the true lumen distal to occlusion segment is
required, usually the Stingray system for the ante-
grade approach and reverse CART for the retrograde
approach. Polymer jacketed guidewires, such as
the Fielder XT (Asahi Intecc) or the Pilot 200, are the
most commonly used wires for knuckling. The Gaia
2nd wire can also be effectively knuckled. It is
preferable to keep the size of the knuckle as small as
possible to minimize vessel trauma. The knuckle
formed by the Fielder XT wire tends to be smaller
than those formed by the Pilot 200 wire. The
knuckle diameter can also be controlled to some
degree by keeping the microcatheter close to
the knuckle. It is important to avoid rotation of the
knuckle wire to avoid knotting the guidewire.
When the knuckle wire is being used as part of
antegrade dissection re-entry it is important to stop
the knuckle before the re-entry zone and use the
CrossBoss to extend the subintimal space into
the re-entry zone, thereby minimizing the sub-
intimal space at the re-entry site and increasing the
JACC: CARDIOVASCULAR INTERVENTIONS VOL. 10, NO. 21, 2017 Harding et al. 2141
NOVEMBER 13, 2017:2135–43 A New Algorithm for CTO Crossing

F I G U R E 3 Algorithm for Antegrade Wire Escalation

The angiographic appearance of the proximal cap can guide initial wire selection in chronic total occlusion intervention. If a high penetration
force guidewire has been used to puncture the proximal cap it is important to step down to a lower penetration force wire, unless the
occlusion is short and the course unambiguous. If a lower or intermediate penetration force wire has been used to cross the chronic total
occlusion body it may be necessary to step up to a higher penetration force wire to puncture through the distal cap into the distal true lumen.
Abbreviation as in Figure 1.

chances of successful true lumen re-entry using
the Stingray system.
In this algorithm anatomic ambiguity rather than
lesion length is the primary reason for considering
use of a knuckle wire and a dissection re-entry
strategy. We also recognize the value of using a
knuckle wire and dissection re-entry techniques in
heavily calcified and tortuous vessels where the
success rates are lower and the risks of perforation
higher with wire escalation strategies. In CTO
lesions longer than 20 mm and in those with a
previous failed attempt, antegrade wire escalation
can result in successful crossing particularly when
other anatomic features are favorable (yielding a
low J-CTO score).
PARALLEL WIRING VERSUS ANTEGRADE
DISSECTION RE-ENTRY
Use of the parallel wire technique and IVUS-guided
wiring are included as options in the antegrade
arm of the main algorithm. The parallel wire tech-
nique has been a widely used and successful
strategy to facilitate the passage of the guidewire
into the true lumen when the first antegrade wire
has failed. In this technique the initial guidewire is
left in place as a marker and to obstruct the
false channel. A second stiffer wire supported by a
microcatheter is then advanced parallel to the first
wire until the point of the first wire is thought to
have deviated; this is often detectable by a subtle
inflection in the course of the first wire. The second
wire is then directed toward the distal target and
advanced into the true lumen.
Antegrade dissection re-entry using the dedicated
Stingray system has been shown to improve proce-
dural success rates and efficiency particularly in those
with high J-CTO scores (19). However, not all lesions
are suitable for antegrade dissection re-entry and
effective use of the Stingray system requires training.
Lack of availability and cost may also limit use
in some countries. For the Stingray system to be
2142 Harding et al.
A New Algorithm for CTO Crossing
successful, it should be used early before any signif-
icant subintimal space expansion has occurred in the
re-entry zone.
When using antegrade wire escalation as the
initial strategy, if the guidewire goes past the distal
cap into the subintimal space a decision needs to be
made on how to proceed. If the initial guidewire
position is close to the distal true lumen it is
reasonable to attempt redirection of the wire into the
distal true lumen. The Gaia series of wires (Asahi
Intecc) are particularly effective for this because of
their high torque control. However, if this fails a
decision needs to be made whether to continue with
wire-based techniques, change to dissection re-
entry, or change to a retrograde approach. This
choice is determined by the presence of interven-
tional collaterals, the operators skill set, equipment
availability, and anatomic factors. A relatively
disease-free re-entry zone, close proximity of the
antegrade wire to the distal true lumen, and
the absence of severe calcification in the re-entry
zone all favor re-entry with the Stingray system.
Conversely, the presence of severe disease, calcifi-
cation, or a bifurcation in the re-entry zone favors
parallel wiring or a retrograde approach.
When the Stingray system is not available and both
antegrade wiring and retrograde strategies have
failed then IVUS-guided wiring may be used as a last
resort. To perform this, a 1.5-mm balloon is advanced
over the antegrade wire and inflated in the subintimal
space to allow delivery of an IVUS catheter. IVUS is
then used to determine the location of the true lumen
and direct a second antegrade high penetration force
wire, such as a Conquest Pro, from the subintimal
space toward the distal true lumen.
RETROGRADE SUBALGORITHM
The retrograde approach is an essential component of
CTO PCI and use of this approach has substantially
increased success rates in complex CTO PCI (7).
A detailed discussion of the retrograde approach
and the related problem solving is beyond the scope
of this article and will be the focus of a subsequent
paper. A brief overview of our approach is discussed
next.
Use of the retrograde approach requires the
presence of an interventional collateral. Failure of
collateral crossing remains the most common cause
of failure of the retrograde approach (20). Once the
retrograde channel is crossed with the guidewire,
the retrograde microcatheter is advanced to the distal
cap. In cases with a nonambiguous vessel course
without other adverse anatomic features
JACC: CARDIOVASCULAR INTERVENTIONS VOL. 10, NO. 21, 2017
NOVEMBER 13, 2017:2135–43
we recommend use of contemporary reverse CART to
facilitate retrograde crossing. In contemporary
reverse CART a small balloon, usually 2.0 mm, is
advanced antegradely as distally as possible and
inflated. An intermediate to high penetration
force wire with good torque control, such as the GAIA
2nd or 3rd, is then advanced retrogradely before there
is subintimal space expansion distal to the CTO and
intentionally directed toward the antegrade balloon.
The antegrade balloon is then deflated and the
retrograde wire advance into the balloon space.
Similar to antegrade wire escalation, use of a
knuckle wire is favored when there is anatomic
ambiguity that cannot be overcome by advancement
of the antegrade wire or when there is a combination
of the following: tortuosity, calcification, and a long
occlusion length. In these cases, once there is overlap
of the retrograde knuckle wire with the antegrade
wire, reverse CART can then be performed. If there
is difficulty making the connection IVUS guidance
should be used to determine the location of
the antegrade and retrograde wires and select the
appropriate strategy. Use of a guide extension
catheter to facilitate reverse CART or so-called
guide-extension reverse CART has become common
practice. This is particularly useful where there is a
significant length of disease or dissection in the target
vessel proximal to the connection site and where
the retrograde microcatheter is unable to reach the
anterograde guide catheter because of long collateral
channel course (21). Once the connection has been
made and the retrograde wire advanced into the
guide or guide extension catheter wire externaliza-
tion can be performed with subsequent antegrade
ballooning and stenting.
WHEN TO STOP
Knowing when to stop is a key issue in CTO PCI. It is
important to balance the potential risks of a signifi-
cant complication with the chance of procedural
success when deciding whether or not to stop the
procedure. Our algorithm provides specific guidance
suggesting that operators should consider stopping a
CTO procedure if the procedure time is >3 h, if more
than 3.7 ml  the estimated glomerular filtration rate
of contrast has been used or if the radiation dose is >5
Gy air kerma unless the procedure is well advanced.
The procedure being well advanced can be defined as
having the antegrade wire in the distal true lumen,
having the stingray catheter in position in the re-
entry zone, or having crossed the collateral channel
with the retrograde wire and microcatheter. These
cutoffs are based on the published literature that
JACC: CARDIOVASCULAR INTERVENTIONS VOL. 10, NO. 21, 2017 Harding et al. 2143
NOVEMBER 13, 2017:2135–43 A New Algorithm for CTO Crossing

suggests the risk of radiation skin injury and contrast of CTO PCI knowledge. The difficulties in applying
nephropathy increases significantly beyond these the hybrid algorithm in the Asia Pacific region has led
limits (22,23). us, the Asia Pacific CTO club, to develop an algorithm
for CTO PCI that is globally relevant. Further studies
CONCLUSIONS are needed to confirm not only the success rates of
CTO PCI using this algorithm, but more importantly
Algorithms provide an important platform for the success of proctoring CTO PCI with this algorithm.
discussion, have proven to be an effective tool
for proctoring, and have advanced the practice
and success of CTO PCI. Rapid technological ADDRESS FOR CORRESPONDENCE: Dr. Scott A.
developments in the area of CTO PCI have led to Harding, Department of Cardiology, Wellington
some increase in CTO PCI success rates, but further Hospital, Private Bag 7902, Wellington South,
improvements are heavily dependent on expansion New Zealand. E-mail: scott.harding@ccdhb.org.nz.

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KEY WORDS chronic, coronary,
intervention, occlusion, percutaneous,
revascularization