Chronic Total Occlusion Wiring: A State-of-the-Art Guide From The Asia Pacific Chronic Total Occlusion Club

Objective: Despite the advances in wire technology and development of algorithm-driven methodology for chronic total occlusion (CTO) intervention, there is a void in the literature about the technical aspects of CTO wiring. The Asia Pacific CTO Club, a group of 10 experienced operators in the Asia Pacific region, has tried to fill this void with this state-of-the-art review on CTO wiring.

Methods: This review explains, for proximal cap puncture: choices of wires, shaping of the wire, use of dual lumen catheter, and method of step-down of wire penetration force for successful wiring. In wiring the CTO body, the techniques of loose tissue tracking, intentional intimal plaque tracking, and intentional subintimal wiring are described in detail. For distal lumen wiring, a blunt distal cap, presence of a distal cap side branch, calcium, and sharp tapered distal stump predict cap toughness, and wire penetration force should be stepped-up in these cases. The importance of choosing between redirection, parallel wiring, and Stingray (Boston Scientific, Marlborough, MA, USA) for angiographic guidance is discussed along with which will be more successful. On the retrograde side, the problems encountered with distal cap puncture and methods to overcome these problems are explained. The method of wiring the CTO body through a retrograde approach depending on the morphology of the CTO is described. Different reverse controlled antegrade and retrograde tracking (CART) wiring methods - including end balloon wiring, side balloon entry, and conventional reverse CART - are explained in detail.

Conclusion: This is a systematic CTO wiring review, which is believed to be beneficial for CTO operators worldwide.