In FAME (Fractional Flow Reserve versus Angiography for Multivessel Evaluation) 3 4, the only recent global PCI vs coronary artery bypass graft (CABG) trial using intracoronary physiology to guide lesion selection for PCI, outcomes following PCI were inferior to surgery at 12 months.

SYNTAX (SYNergy between percutaneous coronary intervention with TAXus and cardiac surgery) II, the only percutaneous coronary intervention (PCI) registry reporting the long-term event rate of the surgical arm of SYNTAX, included centres able to achieve a success rate in CTO recanalisation of 87% 3. Andreas Gruentzig said that “… the total closure is a real problem, if we cannot solve the total closure problem we probably will never really address the question of multivessel dilatation”. Collateral recruitment avoids or limits fibrotic transformation, preserving viability and, in part, the function of the supplied myocardium. The ageing population may, in part, explain this persistently high percentage. When primary angioplasty was introduced in the 1990s, many expected a dramatic fall in the incidence of chronic total occlusions (CTO), but the incidence of occluded coronary vessels among patients with significant coronary artery disease has remained at 16-18% in recent large series 1 2. This review reports a detailed overview of the history, indications and treatment strategies for CTO recanalisation and hopes to increase interest among new, and especially young, operators in this demanding, rapidly evolving field of interventional cardiology. Despite this evidence, CTO recanalisation is grossly underutilised. Although there has been no improvement in prognosis in randomised trials to date, they, and other controlled registries of thousands of patients, confirm the pivotal role of CTO recanalisation in the treatment of angina and dyspnoea and an improvement in quality of life. The contemporary procedural success rate is 80-90% with a reduction in complications. Percutaneous treatment of coronary chronic total occlusions (CTO) has advanced greatly since its advent in the late 1970s through the development of dedicated wires and microcatheters, the improved skills of highly experienced operators and the adoption of new sophisticated strategies to guide procedural planning.

Hastings and smith size chart