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Chronic total occlusion (CTO) percutaneous coronary intervention (PCI) has been rapidly evolving in different parts of the world. We examined the clinical and angiographic characteristics and procedural outcomes of 1,079 consecutive CTO PCIs performed in 1,063 patients at 10 centers in the Middle East, North Africa, Turkey, and Asia regions between 2018 and 2022. The mean age was 61 ± 10 years and 82% of the patients were men. The prevalence of diabetes (49%) and previous PCI (50%) was high. The most common target vessel was the right coronary artery (51%), followed by the left anterior descending artery (33%) and the circumflex artery (15%). The mean Japanese CTO score was 2.1 ± 1.2 and mean PROGRESS-CTO (Prospective Global Registry for the Study of Chronic Total Occlusion Intervention) score was 1.2 ± 1.0. The technical and procedural success rates were high (91% and 90%, respectively) with a low incidence (1.6%) of in-hospital major adverse cardiac events. The incidence of perforation was 4.6% (n = 50): guidewire exit was the most common mechanism of perforation (48%) and 14 patients required pericardiocentesis (28%). Antegrade wire escalation was the most common crossing strategy used (91%), followed by retrograde approach (24%) and antegrade dissection and re-entry (12%). Median contrast volume, air kerma radiation dose, and fluoroscopy time were 300 (200 to 400) ml, 3.7 (2.0 to 6.3) Gy, and 40 (25 to 65) minutes, respectively. In conclusion, high success and acceptable complication rates are currently achieved at experienced centers in the Middle East, North Africa, Turkey, and Asia regions using a combination of crossing strategies., Competing Interests: Declaration of Competing Interest Dr. ElGuindy receives consulting honoraria from Medtronic, Boston Scientific, Asahi Intecc, Terumo; proctorship fees from Medtronic, Boston Scientific, Asahi Intecc, Terumo. Dr. Rafeh receives proctor and speaker honoraria from Boston Scientific and Shockwave medical. Dr. Sandoval previously served on the Advisory Boards for Roche Diagnostics and Abbott Diagnostics without personal compensation and has also been a speaker without personal financial compensation for Abbott Diagnostics. Dr. Burke is a shareholder in MHIC, Egg Medical. Dr. Brilakis receives consulting/speaker honoraria from Abbott Vascular, American Heart Association (associate editor Circulation), Amgen, Asahi Intecc, Biotronik, Boston Scientific, Cardiovascular Innovations Foundation (Board of Directors), ControlRad, CSI, Elsevier, GE Healthcare, IMDS, InfraRedx, Medicure, Medtronic, Opsens, Siemens, and Teleflex; receives research support from Boston Scientific, GE Healthcare; is an owner of Hippocrates LLC; is a shareholder in MHI Ventures, Cleerly Health, Stallion Medical. The remaining authors have no competing interests to declare., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Antegrade dissection reentry with Stingray device (Boston Scientific, Marlborough, MA) accounts for 20-34% of the chronic total occlusion (CTO) cases in the various hybrid operators' CTO registries and is an important component of CTO crossing algorithms. The Stingray device can facilitate antegrade dissection and reentry, however its use is low outside North America and Europe. The Asia Pacific CTO Club along with three experience Stingray operators from the US, Europe and India, created an algorithm guiding use of the CrossBoss and Stingray catheter. This APCTO Stingray algorithm defines when to use the CrossBoss and Stingray device recommending a reduction in CrossBoss use except for in-stent restenosis lesions and immediate transition from knuckle wiring to the Stingray device. When antegrade wiring fails, choice of Stingray-facilitated reentry versus parallel wiring depends on operator experience, device availability, cost concerns, and anatomical factors. When the antegrade wire enters the subintimal space, we recommend using a rotational microcatheter to produce a channel and deliver the Stingray balloon-so called the "bougie technique." We recommend early switch to Stingray rather than persisting with single wire redirection or parallel wire. We recommend choosing a suitable reentry zone based on preprocedural computer tomography or angiogram, routine use of stick and swap, routine use of Subintimal TRAnscatheter Withdrawal (STRAW) through the Stingray balloon, and the multi stick and swap technique. We believe these techniques and algorithm can facilitate incorporation of the Stingray balloon into the practice of CTO interventionists globally., (© 2019 The Authors. Catheterization and Cardiovascular Interventions published by Wiley Periodicals, Inc.)