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While there has been a steady stream of research on chief technology officers (CTOs), studies specifically examining the expanding role of CTOs, particularly in the areas of environmental, social, and governance (ESG), remain scarce. Despite extensive research on boards of directors (BODs), chief executive officers (CEOs), and corporate social responsibility (CSR) committees, there is a significant lack of research on the role of CTOs in integrating ESG considerations into technology development and operations. To fill this gap, this study investigated the impact of CTO characteristics (personal, positional, and career-related) on corporate ESG performance. Based on previous studies, we created a conceptual model and proposed 12 hypotheses. A sample of 218 publicly traded corporations in Korea was selected, and a structural equation model was used to test the fit of the research model and hypotheses. The results indicate that the positional characteristics of the CTO positively affect a corporation's ESG performance, whereas the career-related characteristics of the CTO negatively affect it. However, personal characteristics did not exhibit significant effects. Therefore, this study underscores the need for corporations to empower technology leaders, such as the CTO, and enable them to play an important role in strategic decision-making. By doing so, organizations can enhance their social responsibility, improve environmental sustainability, and maintain competitiveness. [ABSTRACT FROM AUTHOR]

Abstract Background Chronic total occlusion (CTO) percutaneous coronary intervention (PCI) carries risk of complications and should be attempted when the anticipated benefits exceed the potential risks. The primary indication for CTO–PCI is symptom improvement. However, the impact of CTO–PCI on angina and subsequent incidence of major adverse cardiovascular event (MACE) rate remains controversial. Our aim was to study the impact of technically successful elective CTO–PCI on the procedural success rate and short-term MACE. The current study was a prospective cohort study that included a total of 80 patients who were referred to our center (Ain Shams University Hospitals) for elective CTO–PCI and underwent technically successful CTO–PCI. Data were collected on patient arrival to our department, and then, the patients were observed during hospital admission to record any In-Hospital MACE. These patients were then followed up for 6 months to record improvement or worsening of their symptoms and to assess occurrence of any MACE including hospitalization and undergoing symptom-driven coronary angiography. Results The mean age of our patients was 56 ± 9.6 years, and 73 patients (91%) were men. Sixty-two patients (77.5%) were done via an antegrade approach, and 18 patients (22.5%) were done via a retrograde approach with an overall procedural success rate of 91.25% (antegrade 93.5%, retrograde 83.3%). The overall mean procedure time was 102 min, the mean contrast volume used was 371 ml, and the mean cumulative air kerma dose was 7.2 Gy. The retrograde group required longer procedure times, larger volumes of contrast and higher exposure to radiation. The overall in-hospital MACE was 8.75%. Sixty-five patients in our study (81.25%) showed an improvement in the grade of their exertional dyspnea or angina within the 6-month follow-up period. Thirteen patients in our study (16.25%) needed re-hospitalization within a 6-month period after PCI. The overall target lesion revascularization rate at 6 months was 8.75%. Conclusions Technically successful CTO PCI in a well-equipped center with highly qualified CTO operators resulted in high procedural success rates and low incidence of short-term MACE.

To evaluate the characteristics and outcomes of patients with a chronic total occlusion (CTO) in a Non-ST Elevation Myocardial Infarction (NSTEMI) cohort. There is limited data on the clinical characteristics, revascularisation strategies and outcomes of patients presenting with a NSTEMI and a CTO. Retrospective analysis of a six-centre percutaneous coronary intervention (PCI) registry in the UK between January 2015 and December 2020 was performed. Patients with a NSTEMI with and without a CTO were compared for baseline characteristics and outcomes. There were 17,355 NSTEMI patients in total of whom 1813 patients had a CTO (10.4 %). Patients with a CTO were more likely to be older (CTO: 67.8 (±11.5) years vs. no CTO: 67.2 (±12) years, p = 0.04), male (CTO: 81.1 % vs.71.9 %, p < 0.0001) with a greater prevalence of cardiovascular risk factors. All-cause mortality at 30 days: HR 2.63, 95 % CI 1.42–4.84, p = 0.002 and at 1 year: HR: 1.87, 95 % CI 1.25–2.81, p = 0.003 was higher in the CTO cohort. CTO patients who underwent revascularisation were younger (Revascularisation 66.4 [±11.7] years vs. no revascularisation 68.4 [±11.4] years, p = 0.001). Patients with failed CTO revascularisation had lower survival (HR 0.21, 95 % CI 0.10–0.42, p < 0.0001). The mean time to revascularisation was 13.4 days. There was variation in attempt at CTO revascularisation between the 6 centres for (16 % to 100 %) with success rates ranging from 65 to 100 %. In conclusion, the presence of a CTO in NSTEMI patients undergoing PCI was associated with worse in-hospital and long-term outcomes. [Display omitted] • We assessed the clinical characteristics and outcomes of patients with a NSTEMI and a co-existing CTO from six UK centres. • Patients with a NSTEMI and CTO were likely to be older, male with increased prevalence of cardiovascular risk factors. • There was large variation in practice of attempted revascularisation of the CTO between centres. • Failed revascularisation of the CTO was associated with lower long term survival. [ABSTRACT FROM AUTHOR]

The percutaneous management of chronic total occlusions (CTO) is a well-established sub-specialty of Interventional Cardiology, requiring specialist equipment, training, and techniques. The heterogeneity of approaches in CTO has led to the generation of multiple algorithms to guide operators in their management. The evidence base for management of CTOs has suffered from inconsistent descriptive and quantitative terminology in defining the nature of lesions and techniques utilised, as well as seemingly contradictory data about improvement in ventricular function, symptoms of angina, and mortality from large-scale registries and randomised controlled trials. Through this review, we explore the history of CTO management and its supporting evidence in detail, with an outline of limitations of CTO-percutaneous coronary intervention and a look at the future of this growing field within cardiology. [ABSTRACT FROM AUTHOR]

Background: Chronic total occlusion (CTO) percutaneous coronary intervention (PCI) carries risk of complications and should be attempted when the anticipated benefits exceed the potential risks. The primary indication for CTO–PCI is symptom improvement. However, the impact of CTO–PCI on angina and subsequent incidence of major adverse cardiovascular event (MACE) rate remains controversial. Our aim was to study the impact of technically successful elective CTO–PCI on the procedural success rate and short-term MACE. The current study was a prospective cohort study that included a total of 80 patients who were referred to our center (Ain Shams University Hospitals) for elective CTO–PCI and underwent technically successful CTO–PCI. Data were collected on patient arrival to our department, and then, the patients were observed during hospital admission to record any In-Hospital MACE. These patients were then followed up for 6 months to record improvement or worsening of their symptoms and to assess occurrence of any MACE including hospitalization and undergoing symptom-driven coronary angiography. Results: The mean age of our patients was 56 ± 9.6 years, and 73 patients (91%) were men. Sixty-two patients (77.5%) were done via an antegrade approach, and 18 patients (22.5%) were done via a retrograde approach with an overall procedural success rate of 91.25% (antegrade 93.5%, retrograde 83.3%). The overall mean procedure time was 102 min, the mean contrast volume used was 371 ml, and the mean cumulative air kerma dose was 7.2 Gy. The retrograde group required longer procedure times, larger volumes of contrast and higher exposure to radiation. The overall in-hospital MACE was 8.75%. Sixty-five patients in our study (81.25%) showed an improvement in the grade of their exertional dyspnea or angina within the 6-month follow-up period. Thirteen patients in our study (16.25%) needed re-hospitalization within a 6-month period after PCI. The overall target lesion revascularization rate at 6 months was 8.75%. Conclusions: Technically successful CTO PCI in a well-equipped center with highly qualified CTO operators resulted in high procedural success rates and low incidence of short-term MACE. [ABSTRACT FROM AUTHOR]

Background/Objectives: Chronic total occlusion (CTO) is a prevalent finding in patients with coronary artery disease and is associated with increased mortality. Prior reports on the efficacy of percutaneous coronary intervention (PCI) compared to optimal medical therapy (OMT) were controversial. Following the emergence of recently published new evidence, a meta-analysis is warranted. The current meta-analysis assessed the effects of PCI compared to OMT in the treatment of CTO. Methods: A structured literature search was performed. Randomized controlled trials (RCTs) and non-randomized controlled studies of interventions were eligible. The primary outcome was an accumulated composite of cardiac mortality, myocardial infarction and target vessel/lesion revascularization events. Results: Thirty-two studies reporting on 11260 patients were included. Of these, 5712 (50.7%) were assigned to the PCI and 5548 (49.3%) were allocated to the OMT group. The primary outcome occurred in 14.6% of the PCI and 20.1% of the OMT group (12 trials, OR 0.66, 95% CI 0.50 to 0.88, p = 0.005, I2 = 67%). Subgrouping demonstrated a consistent reduction in the primary outcome for the PCI group in RCTs (six trials, OR 0.58, 95% CI 0.33 to 0.99, p = 0.05). The primary outcome reduction was irrespective of the study design, and it was replicable in sensitivity and subgroup analyses. Advantages in other outcomes were rather related to statistical pooling effects and dominated by observational data. Conclusions: CTO-PCI was associated with improved patient-oriented primary outcome compared to OMT in a study-level meta-analysis. This composite outcome effect was mainly driven by target vessel treatment, but a significant reduction in mortality and myocardial infarction was observed, irrespectively. These findings have hypothesis-generating implications. Future RCTs with adequate statistical power are eagerly awaited. [ABSTRACT FROM AUTHOR]

Scant data exploring potential suboptimal physiological results after angiographic successful percutaneous coronary intervention (PCI) of chronic total occlusion (CTO) are available. Sixty cases of successful CTO-PCI were selected for this retrospective analysis. Post-CTO-PCI angiography-based fractional flow reserve was computed using the Murray-based fractional flow reserve (μFR) software. Vessel-specific μFR, residual trans-stent gradient (TSG) and corrected TSGstent were calculated. In physiological suboptimal results (μFR < 0.90), the virtual pullback pressure gradient (PPG) curves were analyzed to localize the main pressure drop-down and characterize the patterns of residual disease. The virtual pullback pressure gradient index (vPPGi) was then calculated to objectively characterize the predominant pattern of residual disease (diffuse vs focal). The physiological result was suboptimal in 28 cases (46.7%). The main pressure drop was localised proximal to the stent in 2 (7.1%), distal in 17 (60.7%) and intra-stent in 9 cases (32.2%). Intra-stent residual disease was diffuse in 7 cases and mixed in 2. Distal residual disease was characterised by a pure focal pattern in 12 cases, diffuse in 2 and mixed in 3. In the predominant diffuse phenotype (vPPGi < 0.65), we found a higher rate of TSG ≥ 0.04 (61.5% vs 20.0%, p = 0.025) and TSGstent ≥ 0.009 (46.2% vs 20.0%, p = 0.017) while in the dominant focal phenotype poor-quality distal vessel was constantly present. In our cohort, post-CTO-PCI suboptimal physiological result was frequent (46.7%). Predominant focal phenotype was constantly associated with poor-quality distal vessel, while in the predominant diffuse phenotype, the rate of TSG ≥ 0.04 and TSGstent ≥ 0.009 were significantly higher. [ABSTRACT FROM AUTHOR]

Chronic total occlusion (CTO) is one of the most severe and sophisticated vascular stenosis because of complete blockage, greater operation difficulty, and lower procedural success rate. This study proposes a hydraulic-driven soft robot imitating the earthworm's locomotion to assist doctors or operators in actively opening thrombi in coronary or peripheral artery vessels. Firstly, a three-actuator bionic soft robot is developed based on earthworms' physiological structure. The soft robot's locomotion gait inspired by the earthworm's mechanism is designed. Secondly, the influence of structure parameters on actuator deformation, stress, and strain is explored, which can help us determine the soft actuators' optimal structure parameters. Thirdly, the relationship between hydraulic pressure and actuator deformation is investigated by performing finite element analysis using the bidirectional fluid–structure interaction (FSI) method. The kinematic models of the soft actuators are established to provide a valuable reference for the soft actuators' motion control. [ABSTRACT FROM AUTHOR]

Objectives. To compare long-term angina pectoris relief of successful versus failed percutaneous coronary intervention of chronic total occlusions (CTO PCI). Background. Previous studies demonstrate better short-term angina pectoris relief of CTO PCI than with optimal medical treatment (OMT), however, data on the long-term effects are lacking. Methods. 295 patients undergoing CTO PCI were analyzed retrospectively, with a follow-up evaluation of symptoms of angina pectoris and all-cause death one to four years after the intervention. The primary outcome was long-term relief of symptoms of angina pectoris. Secondary outcomes included a composite of major adverse cardiovascular events (MACE), including all-cause death, myocardial infarction, stroke, and later target vessel revascularization (TVR). At follow-up, patients were interviewed for symptoms of angina pectoris at 1, 6, 12, and 22 to 48 months after the intervention. Results. CTO PCI was successful in 225 (76%) patients and failed in 70 (24%) patients. Short-term (six months) relief of angina pectoris was observed in both groups, but only the successful CTO PCI group showed long-term relief. The Kaplan–Meier curves of all-cause death did not differ between the groups (p =.715). The final follow-up was a mean (range) of 37 (25 to 44) months after the intervention in the successful CTO PCI group, and 33 (28 to 48) months in the failed CTO PCI group. Conclusions. Successful CTO PCI is associated with better long-term relief of symptoms of angina pectoris compared to failed CTO PCI. [ABSTRACT FROM AUTHOR]

The present article deals with the indications for revascularization of chronic total occlusions (CTO) of the coronary arteries. The introduction section briefly summarizes the history and development of CTO PCI. The main content of the paper is divided into three sections: the first one summarizes the current American and European societies of cardiology guidelines on CTO PCI; the second one provides a reflection on the most important aspects of the indication process from the most recent expert consensus; and the third one conveys the author’s personal experience with indicating patients for CTO recanalization. The paper also includes an overview of randomized trials on CTO PCI. [ABSTRACT FROM AUTHOR]

Percutaneous coronary intervention (PCI) in patients with chronic total occlusion is commonly performed despite unclear long-term benefits. The goal of this study was to evaluate the postprocedural outcome of patients with chronic total occlusion intervention. The National Inpatient Sample database, years 2016-2020, was studied using International Classification of Diseases, Tenth Revision codes. Patients with chronic total occlusion interventions were compared with patients without chronic total occlusion. We evaluated postprocedural mortality and complications. PCI in patients with chronic total occlusion was associated with higher total inhospital mortality and all postprocedural complications. A weighted total of 10,059,269 patients underwent PCI, with 259,574 having chronic total occlusion. The chronic total occlusion group had a 3.17% mortality rate vs 2.57% of nonchronic total occlusion PCIs (odds ratio [OR] 1.24; 95% confidence interval [CI], 1.18-1.31; P <.001). Using multivariate analysis adjusting for basline charcteristics and high risk features such as age, sex, race, diabetes mellitus, chronic kidney disease, systolic heart failure, 3-vessel PCI, hypertension, chronic obstructive pulmonary disease, ST-elevation myocardial infarction, non-ST-elevation myocardial infarction, prior PCI, history of coronary artery bypass graft, history of anemia, smoking status, atrial fibrillation/flutter, valvular heart disease, and , history of stroke, chronic total occlusion PCI remained significantly associated with higher total mortality (OR 1.07; 95% CI, 1.02-1.13; P =.02). Patients with chronic total occlusion compared with nonchronic total occlusion PCI had also higher rates of myocardial infarction (OR 2.85; 95% CI, 2.54-3.21; P <.001), coronary perforation (OR 6.01; 95% CI, 5.25-6.89; P <.001), tamponade (OR 3.36; 95% CI, 2.91-3.88; P <.001), contrast-induced nephropathy (OR 2.05; 95% CI, 1.45-2.90; P <.001), procedural bleeding (OR 3.57; 95% CI, 3.27-3.89; P <.001), and acute postprocedural respiratory failure (OR 2.07; 95% CI, 1.81-2.36; P <.001). All postprocedural complications were more than 3 times the nonchronic total occlusion patients (OR 3.45; 95% CI, 3.24-3.67; P <.001). Using a large national inpatient database, PCI performed in patients with chronic total occlusion was associated with significantly much higher mortality and postprocedural complications compared with PCI in nonchronic total occlusion patients. [ABSTRACT FROM AUTHOR]

Chronic total coronary occlusions (CTO) occur in up to 50 % of patients with coronary artery disease by angiography. In CTO-patients, clinically significant arrhythmia is potentially important and insufficiently investigated. Therefore, the purpose of the CTO-ARRHYTHMIA study was to investigate the incidence of loop recorder detected clinically significant arrhythmias and the effect on arrhythmias of revascularization by CTO-PCI. The study is an independent sub-study of the NOrdic-Baltic Randomized Registry Study for Evaluation of PCI in Chronic Total Coronary Occlusion (NOBLE-CTO); ClinicalTrials.gov Identifier NCT03392415. NOBLE-CTO prospectively collects procedural data, quality of life measures, echocardiographic and cardiac MRI findings before and after treatment as well as clinical outcomes in all CTO patients that may be treated by PCI. • Design of randomized registry • Study of complex arrhythmias using implantable loop recorder in cto patients • Randomization to OMT or OMT + CTO PCI [ABSTRACT FROM AUTHOR]

Guiding catheter extensions (GCEs) have become indispensable tools in the modern approach to percutaneous coronary intervention (PCI). The support offered during complex PCI of uncrossable, or tortuous lesions is particularly valuable in the setting of chronic total occlusions (CTO), both for conventional anterograde wire escalation and for anterograde or retrograde dissection and re-entry techniques. This EuroCTO consensus document describes the use of GCE during CTO recanalization and provides a practical guide to anatomies and techniques in which these devices are applicable. We describe the peculiar features of the most-used device and the practical technique for GCE delivery in standard PCI; further specific indications for antegrade and retrograde CTO PCI are discussed in a specific section. In the antegrade approach, the GCEs may be useful to increase support or facilitate antegrade dissection and re-entry techniques, while in the retrograde approach for reverse controlled antegrade and retrograde tracking, to increase retrograde support for gear delivery, for treatment of CTO in bifurcation and ipsilateral externalization with a single guide catheter. The last section of the paper describes GCE-related complications, challenges, limitations, and future perspectives. [Display omitted] • GCEs have become indispensable tools in the modern approach to PCI and for CTO PCI. • GCEs in CTO PCI can be used to increase support for both antegrade and retrograde approaches, facilitating the delivery of wires, microcatheters, and balloons. • The use of GCE is helpful also in antegrade or retrograde dissection and re-entry techniques, such as reverse controlled antegrade and retrograde subintimal tracking to achieve wire connection. [ABSTRACT FROM AUTHOR]

Chronic total occlusion (CTO) is one of the most severe and sophisticated vascular stenosis because of complete blockage, greater operation difficulty, and lower procedural success rate. This study proposes a hydraulic-driven soft robot imitating the earthworm’s locomotion to assist doctors or operators in actively opening thrombi in coronary or peripheral artery vessels. Firstly, a three-actuator bionic soft robot is developed based on earthworms’ physiological structure. The soft robot’s locomotion gait inspired by the earthworm’s mechanism is designed. Secondly, the influence of structure parameters on actuator deformation, stress, and strain is explored, which can help us determine the soft actuators’ optimal structure parameters. Thirdly, the relationship between hydraulic pressure and actuator deformation is investigated by performing finite element analysis using the bidirectional fluid–structure interaction (FSI) method. The kinematic models of the soft actuators are established to provide a valuable reference for the soft actuators’ motion control.

In the aging society, the issue of coronary chronic total occlusion (CTO) has become a challenge for invasive cardiologists. Despite the lack of clear indications in European and American guidelines, the rates of percutaneous coronary interventions (PCI) for CTO increased over the last years. Well-conducted randomized clinical trials (RCT) and large observational studies brought significant and substantial progress in many CTO blind spots. However, the results regarding the rationale behind revascularization and the long-term benefit of CTO are inconclusive. Knowing the uncertainties regarding PCI CTO, our work sought to sum up and provide a comprehensive review of the latest evidence on percutaneous recanalization of coronary artery chronic total occlusion. [ABSTRACT FROM AUTHOR]

Objective: CTO is defined as 100% occlusion of a coronary artery for more than one month. Nutritional status has been shown to be a prognostic marker in many clinical situations. CONUT and PNI scores are objective indices that can be calculated based on simple blood parameters and can be used to evaluate the nutritional status of patients. The aim of this study was to examine the effect of nutritional status assessed by CONUT and PNI on all-cause mortality in patients with CTO. Material and Method: The retrospective study included 516 patients who had CTO on coronary angiography. The nutritional status of the patients was evaluated with PNI and CONUT scores, and categorical groups were formed according to these results and compared. Results: All-cause mortality occurred in 127 (24.6%) patients during median follow-up period of 48 months. At the end of the follow-up period, the patients were divided into two groups as survival and non-survival. In terms of all-cause mortality, mean PNI score (47,87±6,31 vs. 42,41±6,57) and median CONUT score (1(2) vs. 3(3)) differed significantly between the surviving and non-surviving groups (p <0.001). Kaplan-Meier analysis showed a significant difference in survival between the PNI and CONUT scores cathegorical groups (p <0.001). Conclusion: Higher CONUT scores and lower PNI scores were found to be associated with poor outcomes in CTO patients. Evaluation and monitoring of nutritional status in CTO patients by these nutritional scores may provide additional prognostic informatio [ABSTRACT FROM AUTHOR]

The study sought to assess the procedural success of rotational atherectomy (RA) in coronary chronic total occlusion (CTO) and to investigate the in-hospital and one-year outcomes following RA. From 2015 to 2019, patients undergoing percutaneous coronary intervention for CTO (CTO PCI) were retrospectively included into the hospital database. The primary endpoint was procedural success. Secondary endpoints were in-hospital and one-year major adverse cardiovascular and cerebral event (MACCE) rates. During the study period of 5 years, 2.789 patients underwent CTO PCI. Patients treated with RA (n = 193, 6.92%) had a significantly higher procedural success (93.26% vs. 85.10%, p = 0.0002) compared to those treated without RA (n = 2.596, 93.08%). Despite a significantly higher rate of pericardiocentesis (3.11% vs. 0.50%, p = 0.0013) in the RA group, the in-hospital and one-year MACCE rate was similar in both groups (4.15% vs. 2.77%, p = 0.2612; 18.65% vs. 16.72%, p = 0.485). In conclusion, RA is associated with higher procedural success for CTO PCI, but has higher risks for pericardial tamponade than CTO PCI without the need for RA. Nevertheless, in-hospital and one-year MACCE rates did not differ in-between both groups. [ABSTRACT FROM AUTHOR]

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Copyright of Nankai Business Review is the property of Nankai Business Review Editorial Office and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

A new chronic total occlusion (CTO) guidewire, Conquest Pro 12 Sharpened Tip (CP12ST), has a stronger penetration force than the original CP12 and a deflection effect that it does not have. The CP12ST enables us to advance into hard plaque that has not ever penetrated, which might change CTO treatment as shown in three cases. [ABSTRACT FROM AUTHOR]

BACKGROUND In ST‐segment–elevation myocardial infarction (STEMI), a concomitant chronic total occlusion (CTO) in a non–infarct‐related artery (NIRA) is associated with adverse outcome. In the case of the infarct‐related artery (IRA) as a donor vessel for collaterals to the CTO, the IRA occlusion may lead to an acute threat to both the immediate IRA and the collaterally supplied CTO area, which has been described as a double‐jeopardy effect. METHODS AND RESULTS We investigated the role of preformed intercoronary collaterals to the CTO originating from either the IRA or NIRA. Data were obtained from 2 hospitals participating in the prospective FITT‐STEMI (Feedback Intervention and Treatment Times in ST‐Segment Elevation Myocardial Infarction) study. From a total cohort of 2102 patients with acute STEMI, 93 patients had single‐vessel CTO in an NIRA and well‐developed intercoronary collaterals to the CTO. In‐hospital mortality differed significantly with respect to the origin of the collaterals. Mortality was 15.2% with collaterals originating from the NIRA, 29.4% with a collateral origin from the IRA proximal to the acute STEMI occlusion, and 3.3% with a collateral origin from the IRA distal to the acute occlusion (P=0.044). A multivariate regression model confirmed that a proximal collateral origin had a significant higher mortality compared with a branching in the distal position from the acute STEMI occlusion (P=0.027; odds ratio = 20.8 [95% CI, 1.4–304.1]). CONCLUSIONS In STEMI with CTO in an NIRA, a CTO collateralization from the IRA distal to the acute occlusion is associated with a better prognosis. This finding challenges the double‐jeopardy assumption as the main cause of adverse outcome in STEMI with CTO in an NIRA. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: NCT00794001.

Abstract A new chronic total occlusion (CTO) guidewire, Conquest Pro 12 Sharpened Tip (CP12ST), has a stronger penetration force than the original CP12 and a deflection effect that it does not have. The CP12ST enables us to advance into hard plaque that has not ever penetrated, which might change CTO treatment as shown in three cases.

Overview: Innovation Research Interchange's (IRI) 2022 in-person meeting of chief technology officers was held in Washington, DC, on September 19–20, 2022. Craig Slavtcheff, executive vice president – chief technology and innovation officer of Campbell Soup Company, hosted the meeting. The CTO Forum took place in conjunction with the National Association of Manufacturers Board of Directors meeting. James Euchner, visiting professor at Aston Business School (UK) and editor-in-chief of Research-Technology Management (RTM), facilitated the meeting. [ABSTRACT FROM AUTHOR]

To understand the themes for Māori subjected to compulsory community treatment orders.The Mental Health (Compulsory Assessment and Treatment) Act 1992 has been utilised in Aotearoa New Zealand for more than three decades. Despite Māori having higher rates of being subject to community treatment orders, there is little research examining their perspectives of its benefits and harms.Thematic analysis of a purposive sample of Māori in Hawke’s Bay, New Zealand.Five themes were developed. Māori described community treatment orders as restrictive and stigmatising. Some Māori described being poorly informed of the structures surrounding the use of community treatment orders and saw it as a mechanism to circumvent information-giving regarding treatment. Counterbalancing these, Māori described community treatment orders as mandating support and saw them as a mechanism to access care. Finally, some described their compulsory treatment status as unimportant and irrelevant.Thematic analysis identified five clear themes from interview participants. Conceptualisation of community treatment orders was largely negative, although Māori acknowledged that being subject to community treatment orders demanded more support from services. Themes of stigma and restriction are common in the literature, however, conception of the use of community treatment orders to bypass consent is novel. The literature describes community treatment orders as providing support, however, in this study, the interpretation suggests a need to lose personal autonomy to receive care, a potentially ‘slippery slope’ towards a two-tier type service. These findings remind services of the importance of attending to cultural elements of care, being clear around the process of consent. In terms of policy, weaving in cultural understanding appears to be important from an Indigenous perspective. [ABSTRACT FROM AUTHOR]

Coronary total occlusions are routinely found in patients suffering from chronic coronary artery disease. Their prevalence is between 20-50% and is higher in patients with prior coronary artery bypass surgery. Patients with CTOs have a higher risk profile, higher Syntax scores and in approximately 80% of the cases, a multi-vessel disease. Advances in technology that supports CTO-PCI and the increasing operator experience in high volume centers has raised important questions about the revascularization strategy. In the majority of cases, the treatment strategy for this group of patients should aim at achieving full revascularization. In this context CABG should be considered the first choice and percutaneous coronary intervention can be considered for patients with less advanced disease. It is not clear, whether successful CTO revascularization (CABG or PCI) have an impact on long-term outcomes. For these reasons, the treatment of patients in the presence of CTOs should be based on the current evidence on the treatment of multivessel coronary disease.

Background: Coronary chronic total occlusion lesions (CTOs) confer an increased risk of arrhythmic events among patients with ischemic cardiomyopathy (ICM) and implantable cardioverter-defibrillator (ICD) carriers, however the impact of CTO recanalization in this population remains unassessed.Aims: Evaluate the impact of CTOs percutaneous coronary interventions (PCI) on arrhythmic events.Methods: Patients with ICM and ICD from the VACTO I-II registries: patients with medically treated CTO (CTO-OMT group) and without CTO (no-CTO group) were compared after inverse-probability-weighting adjustment (IPWT) with a similar population of consecutive patients undergoing CTO-PCI. The primary endpoint was appropriate ICD therapy. The secondary endpoint was all-cause mortality.Results: The total of 622 patients (mean age 67 ± 10 years, mean left ventricular ejection fraction 36 ± 11%) included in the analysis was composed by: CTO-PCI patients n = 113, CTO-OMT patients n = 286, no-CTO patients n = 223. In the CTO-PCI group, compared to the CTO-OMT group, 5-year Kaplan Meier estimates for appropriate ICD therapy (20.4% vs. 56.4%, IPW-adjusted HR: 0.45, 95% CI 0.29-0.71) and mortality (8.8% vs. 23%, IPW-adjusted HR: 0.43, 95% CI 0.22-0.85) were lower, driven by infarct related artery CTO (IRA-CTO) PCI, while similar to those occurring in the no-CTO group.Conclusions: In this large population, those with CTO receiving PCI had lower arrhythmic event rates and lower mortality compared to the CTO-OMT group, while showing an event rate similar to no-CTO patients. Sensitivity analyses suggest that the beneficial effect on the arrhythmic outcome was driven by IRA-CTO revascularization.Classification: Chronic total occlusion. [ABSTRACT FROM AUTHOR]

Background: This study highlights the prevalence and conservative management strategies of iatrogenic ascending aortic dissection after percutaneous intervention (PCI) of chronic total occlusion (CTO)., Methods: Retrospective analysis on patients who underwent CTO PCI from one medical center from 2020 to 2022 was performed by two operators. Data was obtained from the Prospective Global Registry for the Study of CTO database., Results: Out of 318 patients, there were six reported cases of iatrogenic ascending aortic dissection. The causes of dissection included guiding catheter trauma, antegrade injection, two retrograde injection, and two cases of balloon rupture after lithotripsy. IVUS-guided stenting of the coronary back to the origin to seal the entry of the dissection flap occurred in two patients. All patients had a conservative management approach. No patient had to undergo urgent surgery., Conclusion: While the incidence remains rare, complications, including aortic dissection, are more frequent in CTO PCI as compared to non-CTO PCI. IVUS can be used to complete coronary intervention so long as the patient remains clinically and hemodynamically stable. Patients should have formal imaging with either transesophageal echocardiogram or computed tomography angiography. The outcomes of patients who experience iatrogenic aortic dissection during CTO PCI with stable coronary disease seem to be better than in patients with acute coronary syndrome., (© 2024 The Author(s). Catheterization and Cardiovascular Interventions published by Wiley Periodicals LLC.)

Dry tamponade is a rare complication of percutaneous coronary intervention. It encompasses a heterogenous pathophysiology and is used to describe hemodynamic compromise secondary to a coronary artery perforation, without free-flowing fluid in the pericardium. Tamponade physiology can result from compressive epicardial, intramyocardial, subepicardial hematomas, or dissecting intramyocardial hematomas. The diagnosis of dry tamponade requires hemodynamic derangement in the context of a compressive hematoma as demonstrated by imaging. Although echocardiography can often help identify dry tamponade, additional studies including right heart catheterization, computed tomography, or cardiac magnetic resonance imaging can inform the exact mechanism and help guide management. This article describes a case of dry tamponade, reviews the existing literature on the topic, and offers expert recommendations on diagnosis and management., (© 2024 Wiley Periodicals LLC.)

Background: Retrograde approach has notably improved success rates of chronic total occlusion (CTO) percutaneous coronary intervention (PCI). However, longer procedural time, increase use of fluoroscopy and contrast dye have been reported in retrograde techniques in CTO PCI. We aimed to study in-hospital and long-term outcomes of retrograde approach versus antegrade approach in CTO PCI., Methods: We searched PubMed, Scopus, WOS, and Cochrane Central until June 2023 to include all relevant studies that compared retrograde approach versus antegrade approach in patients with CTO PCI. We synthesized the outcome data using a random-effects model, expressing the effect estimates as odds ratios (OR) or mean difference (MD) with corresponding 95 % confidence intervals (CI)., Results: A total of 18 studies comprising 21,276 patients were included in the analysis. Regarding in-hospital outcomes, antegrade approach was associated with lower odds of MACE (OR= 0.34, 95 % CI: 0.23 to 0.51), all-cause mortality (OR= 0.35, 95 % CI: 0.19 to 0.64), MI (OR= 0.36, 95 % CI: 0.25 to 0.53), urgent pericardiocentesis (OR= 0.27, 95 % CI: 0.16 to 0.46), CIN (OR= 0.46, 95 % CI: 0.33 to 0.65), procedural complications (OR= 0.52, 95 % CI: 0.33 to 0.83), target vessel perforation (OR= 0.45, 95 % CI: 0.32 to 0.64). while antegrade was associated with higher success rates (OR= 1.16, 95 % CI: 1.1 to 1.22)., Conclusion: Compared to antegrade technique, retrograde was associated with higher risk for in-hospital and long-term adverse events, and preferably should be performed in more complex CTO lesions., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024. Published by Elsevier Inc.)

Background: When antegrade recanalization of femoropopliteal and/or infrapopliteal occlusions fails, retrograde access has become an established option. To evaluate the results of combined antegrade and retrograde recanalization of femoropopliteal and infrapopliteal occlusions, patients undergoing secondary retrograde recanalization attempts were analyzed retrospectively., Methods: The primary end point was the success of the procedure (successful occlusion crossing using the antegrade/retrograde technique). Secondary end points include complication rate, primary patency and target lesion revascularization (TLR) rate, amputation rate, changes in ankle-brachial index, and Rutherford-Becker class. Predictors for procedure failure and TLR were analyzed., Results: We included 888 patients: 362 with femoropopliteal (group 1), 353 with infrapopliteal (group 2), and 173 with multilevel (group 3) recanalization. Critical limb-threatening ischemia was present in group 1, 2, and 3 in 36%, 62%, and 76% of patients, respectively. The intervention was successful in 92.5%, 93.8%, and 90.8% of the respective cases (P = .455). The overall peri-interventional complication rate was 7.2%. At 6, 12, and 24 months, primary patency was highest in group 1 (63.9%, 45.8%, and 33.3%), followed by group 3 (59.8%, 46.1%, and 33.3%), and group 2 (58.5%, 43.1%, and 30.4%; P = .537). The risk of undergoing repeated TLR within 24 months was 31.4% for group 1, 39.1% for group 2, and 45.7% for group 3. At 24 months, the survival rates in groups 1, 2, and 3 were 93.8%, 79.4%, and 87.5%, respectively. Over 24 months, 75 patients (8.4%) had to undergo amputation. Significant improvements in both ankle-brachial index and Rutherford-Becker class were present at discharge as well as at 6, 12, and 24 months (P < .001). Dialysis dependency was a predictor of unsuccessful antegrade/retrograde recanalization (P = .048). Lesion length (P = .0043), dialysis (P = .033), and recanalization level (P = .013) increase the risk of TLR., Conclusions: Using a combined antegrade/retrograde access, recanalization of occluded femoropopliteal and/or infrapopliteal arteries can be achieved in a large number of cases. Owing to the high rate of repeated TLR across all lesion localizations, the indication for antegrade and retrograde recanalization may be limited to patients with critical limb-threatening ischemia., Competing Interests: Disclosures E.N. reports honoraria received from Bard-BD, Boston Scientific Corp, Abbott Vascular, Medtronic, ShockWave, and iVascular. T.Z. reports honoraria received from Abbott Vascular, Veryan, Biotronik, Boston Scientific Corp., Cook Medical, W. L. Gore & Associates, Medtronic, Philips-Spectranetics, and Shockwave. T.Z. has consulted for Boston Scientific Corp., W. L. Gore & Associates, Medtronic, Veryan, Intact Vascular, Shockwave, Bayer, and Vesper Medical and has received Research, clinical trial, or drug study funds received from 480 biomedical, Bard Peripheral Vascular, Veryan, Biotronik, Cook Medical, W. L. Gore & Associates, Medtronic, Philips, Terumo, TriReme, Shockwave, Med Alliance, Intact Vascular, and B. Braun. T.Z. Owns common stock in QT Medical. D.W. reports honoraria received from Abiomed, AstraZeneca, Boston, Biotronik, Böhringer, Novartis, and Medtronic., (Copyright © 2024. Published by Elsevier Inc.)

Background: There are limited contemporary data on the impact of success vs. failure on the outcomes of chronic total occlusion (CTO) percutaneous coronary intervention (PCI). Methods: We conducted a systematic review and a meta-analysis of contemporary studies that compared the outcomes in patients who underwent successful vs. failed contemporary (2010 onwards) CTO PCI. We performed a sensitivity analysis limited to studies that started enrollment after the publication of the hybrid algorithm in 2012. Results: We included five studies with a total of 6,084 patients (successful CTO PCI n = 4,861, failed CTO PCI n = 1,223). During a median follow-up time of 12 months (range 6–60 months), successful CTO PCI was associated with a lower risk of major adverse cardiovascular events [OR: 0.61, 95% CI (0.41, 0.92), p = 0.02, I2 = 63%] and all-cause death [OR: 0.57, 95% CI (0.33, 0.99), p = 0.05, I2 = 60%]. Both groups had similar risk of myocardial infarction (MI) [OR 0.69, 95% CI (0.43, 1.10), p = 0.38, I2 = 80%], target vessel revascularization (TVR) [OR: 0.56, 95% CI (0.25, 1.27), p = 0.17, I2 = 80%], and stroke [OR: 0.52, 95% CI (0.14, 1.91), p = 0.33, I2 = 0%]. Conclusion: In contemporary practice, successful CTO PCI was associated with a lower incidence of MACE driven by lower all-cause mortality compared with failed CTO PCI at a median follow-up of 1 year. [ABSTRACT FROM AUTHOR]

BackgroundDistal radial access (DRA) was recently introduced in the hopes of improving patient comfort by allowing the hand to rest in a more ergonomic position throughout percutaneous coronary interventions (PCI), and potentially to further reduce the rate of complications (mainly radial artery occlusion, [RAO]). Its safety and feasibility in chronic total occlusion (CTO) PCI have not been thoroughly explored, although the role of DRA could be even more valuable in these procedures.MethodsFrom 2016 to 2021, all patients who underwent CTO PCI in 3 Hungarian centers were included, divided into 2 groups: one receiving proximal radial access (PRA) and another DRA. The primary endpoints were the procedural and clinical success and vascular access-related complications. The secondary endpoints were major adverse cardiac and cerebrovascular events (MACCE) and procedural characteristics (volume of contrast, fluoroscopy time, radiation dose, procedure time, hospitalization time).ResultsA total of 337 consecutive patients (mean age 64.6 ± 9.92 years, 72.4% male) were enrolled (PRA = 257, DRA = 80). When compared with DRA, the PRA group had a higher prevalence of smoking (53.8% vs. 25.7%, SMD = 0.643), family history of cardiovascular disease (35.0% vs. 15.2%, SMD = 0.553), and dyslipidemia (95.0% vs. 72.8%, SMD = 0.500). The complexity of the CTOs was slightly higher in the DRA group, with higher degrees of calcification and tortuosity (both SMD >0.250), more bifurcation lesions (45.0% vs. 13.2%, SMD = 0.938), more blunt entries (67.5% vs. 47.1%, SMD = 0.409). Contrast volumes (median 120 ml vs. 146 ml, p = 0.045) and dose area product (median 928 mGy×cm2 vs. 1,300 mGy×cm2, p < 0.001) were lower in the DRA group. Numerically, local vascular complications were more common in the PRA group, although these did not meet statistical significance (RAO: 2.72% vs. 1.25%, p = 0.450; large hematoma: 0.72% vs. 0%, p = 1.000). Hospitalization duration was similar (2.5 vs. 3.0 days, p = 0.4). The procedural and clinical success rates were comparable through DRA vs. PRA (p = 0.6), moreover, the 12-months rate of MACCE was similar across the 2 groups (9.09% vs. 18.2%, p = 0.35).ConclusionUsing DRA for complex CTO interventions is safe, feasible, lowers radiation dose and makes dual radial access more achievable. At the same time, there was no signal of increased risk of periprocedural or long-term adverse outcomes.

Emergency coronary artery bypass surgery (eCABG) is a serious complication of chronic total occlusion (CTO) percutaneous coronary artery intervention (PCI). We examined the incidence and outcomes eCABG among 14,512 CTO PCIs performed between 2012 and 2023 in a large multicenter registry. The incidence of eCABG was 0.12% (n = 17). Mean age was 68 ± 6 years and 69% of the patients were men. The most common reason for eCABG was coronary perforation (70.6%). eCABG patients had larger target vessel diameter (3.36 ± 0.50 vs. 2.90 ± 0.52; p = 0.003), were more likely to have moderate/severe calcification (85.7% vs. 45.8%; p = 0.006), side branch at the proximal cap (91.7% vs. 55.4%; p = 0.025), and balloon undilatable lesions (50% vs. 7.4%; p = 0.001) and to have undergone retrograde crossing (64.7% vs. 30.8%, p = 0.006). eCABG cases had lower technical (35.3% vs. 86.7%; p < 0.001) and procedural (35.3% vs. 86.7%; p < 0.001) success and higher in-hospital mortality (35.3% vs. 0.4%; p < 0.001), coronary perforation (70.6% vs. 4.6%; p < 0.001), pericardiocentesis (47.1% vs. 0.8%; p < 0.001), and major bleeding (11.8% vs. 0.5%; p < 0.001). The incidence of eCABG after CTO PCI was 0.12% and associated with high in-hospital mortality (35%). Coronary perforation was the most common reason for eCABG. • Emergency coronary artery bypass surgery (eCABG) is a serious complication of CTO PCI. • The incidence of eCABG after CTO PCI was 0.12% and associated with high in-hospital mortality in a large multi-center CTO PCI registry. • Coronary perforation was the most common reason for eCABG. [ABSTRACT FROM AUTHOR]

An adaptive quantum class topper optimization (AQCTO) technique is studied in this paper. The algorithm is designed for fine-tuning of the controller's optimal gain for automatic generation control (AGC) in a nonlinear interconnected power system. A thermal generating unit with a reheat turbine, generation rate constant, and governor dead band is included in each area of the power system. A three-degree-of-freedom-proportional integral derivative (3DoF-PID) controller structure is studied while building a proper AGC. The suggested AQCTO method is used to optimize the controller parameters. The performance of the AQCTO-based 3DoF-PID is analyzed separately for step and random load perturbation. AQCTO-based 3DoF-PID controllers are analyzed against AQCTO-based PI, ID, and PID controllers in terms of performance. The 3DoF-PID controller outperforms existing optimization techniques such as biogeography-based optimization, class topper optimization (CTO), and particle swarm optimization (PSO) in terms of integral square error (ISE) by 17%, 10%, and 57.67%, respectively. In addition, an inter-line power flow controller (IPFC) is strategically placed to increase the system's performance. Based on OPAL-RT, the ideal position of IPFC is also investigated in a real-time environment. The suggested optimization algorithm's exploitive, explorative, minima avoidance, and global convergence capabilities are then tested using benchmark functions. [ABSTRACT FROM AUTHOR]

Background: Coronary vascular function of a chronic coronary total occlusion (CTO) immediately after recanalization is known to be poor and to be partially improved by pre-treatment with loading dose of ticagrelor vs. clopidogrel. It is unknown if this vascular dysfunction is maintained at long-term follow-up and may be improved by 1-year dual antiplatelet therapy (DAPT).Methods: The TIGER is a prospective, open-label, two parallel-group controlled clinical trial, which 1:1 randomized 50 CTO patients to pre-PCI loading dose and subsequent 1-year DAPT with ticagrelor vs. clopidogrel. Coronary blood flow (CBF) under stepwise adenosine infusion was assessed after drug loading dose and at follow-up and compared between the two drug groups, adjusting for time of follow-up.Results: Out of 50 patients with index CBF evaluation, 38 (76%) patients underwent angiographic follow-up (23 and 15 at 1 and 3-year, respectively) and Doppler data was available in 35 (70%). A high CBF area under the curve (AUC), already observed after loading dose in ticagrelor vs. clopidogrel group (p = 0.027), was maintained at follow-up (AUC 34815.22 ± 24,206.06 vs. AUC 22712.47 ± 13,768.95; p = 0.071). Specifically, whereas high ticagrelor loading dose-related CBF was sustained at follow-up (p = 0.933), clopidogrel loading dose-related CBF increased at follow-up (p = 0.039).Conclusion: The TIGER trial showed that DAPT with ticagrelor maintained a non-significantly higher CBF in a recanalized CTO as compared to clopidogrel, whose treated patients exhibit a lower CBF immediately after PCI with a significant increase at follow-up. The clinical value of such sustained high coronary flow should be evaluated in a larger group of patients.Clinical Trial Registration: https://clinicaltrials.gov/ct2/show/NCT02211066 (ClinicalTrials.gov number NCT02211066). [ABSTRACT FROM AUTHOR]

The case report presents two views on the concept of “triple combination” in treating a particular patient with coronary artery disease. The first, somewhat untraditional meaning of the two-word expression is used to describe an unusual case of three chronic total occlusions (CTO) in three different coronary territories clinically manifested by heart failure in the setting of ischaemic cardiomyopathy. All the occlusions were gradually recanalized using CTO PCI techniques with a good angiographic and clinical effect. There was a marked improvement in the original systolic left ventricular dysfunction. The individual procedures are illustrated by images and accompanied by general information on CTO PCI. A second meaning of the words “triple combination” – in a more traditional pharmacotherapeutic sense – represents a fixed combination of three antihypertensive and lipid-lowering drugs which were used in the same patient to optimize the secondary preventive therapeutic regimen. [ABSTRACT FROM AUTHOR]

Background: The modes of failure of coronary polymer-jacketed guidewires have received limited study.Methods: We queried the Manufacturer and User Facility Device Experience (MAUDE) database between January 2011 and December 2020 for reports on coronary polymer-jacketed guidewires and retrieved 254 reports.Results: The most common failure mode was failure of the guidewire to cross (36.2%), followed by guidewire fracture (35%), peeling of the polymer jacket (13.8%), failure to retrieve the guidewire (13.8%), and guidewire unraveling (4.7%). Guidewire fracture was more common with soft (37.3%) compared with stiff (23.8%) guidewires. Failure of retrieval was only reported with soft guidewires (9%). Coronary perforation and dissection occurred in 19.7% and 7.9% of the reports, with more reports with stiff as compared with soft guidewires (45.2% vs. 14.6% for perforation and 21.4% vs. 5.3% for dissection).Conclusions: The most common failure modes of polymer-jacketed guidewires during percutaneous coronary intervention are failure to cross the lesion, guidewire fracture, and peeling of the polymer jacket. Coronary perforations were more common with stiff whereas wire fracture was more common with soft polymer-jacketed guidewires. [ABSTRACT FROM AUTHOR]

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Objective: Data involved the association between myocardial ischaemia and the outcome for unrevascularized coronary chronic total occlusion (CTO) patients were limited. The purpose of this study was to evaluate the predictive value of ischaemia detected by single photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI) for the adverse events in unrevascularized CTO patients. We further explored whether ischaemia generated from CTO vessel can independently predict the outcome. Methods: Patients with at least one unrevascularized CTO on coronary angiography were enrolled in this study. Exercise stress/rest SPECT MPI was performed in all patients. All patients were then followed by telephone interview and reviewing of medical records. Results: Patients with ischaemia experienced significantly higher rate of adverse events than non-ischaemia patients (40.7% vs 7.1%, P = 0.002). Ischaemia demonstrated on MPI [odds ratio (OR) = 7.656; 95% confidence interval (CI) 1.598–36.677; P = 0.011] was an independent predictor for adverse events. Moreover, CTO-ischaemia (OR = 5.466; 95% CI 1.015–29.420; P = 0.048), non-CTO ischaemia (OR = 29.174; 95% CI 3.245–262.322; P = 0.003), mixed-ischaemia (OR = 7.130, 95% CI 1.257–40.445; P = 0.027) were all independent predictors for outcome. Conclusion: Ischaemia demonstrated on MPI, especially CTO-ischaemia were independent predictors for the adverse events. SPECT MPI can aid to identify patients at risk of adverse events, who may benefit from subsequent CTO percutaneous coronary intervention. [ABSTRACT FROM AUTHOR]

Abstract Even skilled CHIP operators can run into multiple complications. Some are unexpected and not related to the operator, and others are fully preventable by careful procedural choices. If those occur, the knowledge of devices and cognitive skills become lifesaving elements and sudden issues need to be dealt with calmly and efficiently.

Remarkable progress has been achieved in chronic total occlusion (CTO) percutaneous coronary intervention (PCI) in recent years, with refinement of the indications and technical aspects of the procedure, imaging, and complication management. Randomized controlled trials and rigorous prospective registries have provided high-quality data on the benefits and risks of CTO PCI. Global collaboration has led to an agreement on nomenclature, indications, endpoint definition, and principles of clinical trial design that have been distilled in global consensus documents such as the CTO Academic Research Consortium. Increased use of preprocedural coronary computed tomography angiography and intraprocedural intravascular imaging, as well as development of novel techniques and structured CTO crossing and complication management algorithms, allow a systematic, stepwise approach to this difficult lesion subset. This state-of-the-art review provides a comprehensive discussion about the most recent developments in the indications, preprocedural planning, technical aspects, complication management, and future directions of CTO PCI. [Display omitted] • The main indication of CTO PCI is symptom relief. • Meticulous pre-procedural planning and systematic crossing attempts are recommended to optimize CTO PCI success rates. • Intravascular imaging can facilitate CTO recanalization and improve long-term outcomes. • A systematic approach to complications can minimize their adverse impact. [ABSTRACT FROM AUTHOR]