How to Build a Successful Coronary Chronic Total Occlusion Program

13.1

Is Chronic Total Occlusion Percutaneous Coronary Intervention for You?

Start with why. Simon Sinek

Should you embark on the trip of learning chronic total occlusion (CTO) percutaneous coronary intervention (PCI)? This is a challenging question with no easy answer. It requires significant introspection and thought. Here are some factors that may be useful in making this decision.

• 1.

  Passion

  Passion is key for going through the learning (and the maintenance) curve of CTO PCI. The CTO operator is passionate to help each patient by achieving excellent results, even among very challenging cases. Although passion can be developed, CTO PCI should be an exciting proposition from the beginning, to power you through the various developmental stages required.

• 2.

  Procedural skills

  Procedural skills can and will be developed and refined while learning CTO PCI, but operators should already be performing complex PCI and have robust technical skills. For example, operators should not be attempting retrograde crossing via epicardial collaterals without being experienced in doing pericardiocentesis. Similarly, operators should not attempt retrograde crossing through the last remaining vessel or through an internal mammary graft unless they are experienced and have access to left ventricular support devices.

• 3.

  Career stage

  Late career stages may be less conducive to starting a CTO PCI program, given many engrained habits that may be difficult to change. This is relative, however, as many late career operators have achieved tremendous success in CTO PCI. Junior operators starting a CTO PCI program may consider working with a more senior partner.

• 4.

  PCI volume

  CTO PCI is for high-volume, not low-volume operators, because procedural volume does correlate with skills.

• 5.

  Approach to failure and complications

  Even the best operators in the world have failures and complications. Failure can be highly frustrating and demoralizing, especially given the often significant effort that goes into planning and executing each case. Being able to accept failure and learn and apply the lessons that failure provides you is a critical step for the CTO operator. Often reattempt cases will be successful.

• 6.

  Improve overall PCI skills

  CTO operators develop several skills that translate in all aspects of non-CTO PCI. CTO PCI can significantly enhance the operator’s armamentarium for treating complex lesions.

• 7.

  Time availability

  Time is needed to attend courses, read, and get proctored. Also early in the learning curve CTO PCI cases can be long, often lasting 2–4 h each.

There are wrong reasons for wanting to do CTO PCI:

• 1.

  Boosting the ego

  Being a competent CTO operator can improve self-esteem, but helping the patient should be the main driving force, especially since failures and complications are certain to occur.

• 2.

  Income generation

  Given procedure complexity and time and effort required, income generation is not good reason for doing CTO PCI, since successful procedures can be lengthy and unsuccessful procedures are billed at the diagnostic catheterization level in the United States. However, acquiring a new skill set can be valuable in today’s job market.

13.2

Learning Chronic Total Occlusion Percutaneous Coronary Intervention: The Goal

As with any training, there are four distinct stages for learning CTO PCI ( Fig. 13.1 ).

Learning CTO PCI starts with mastering antegrade techniques, first antegrade wire escalation (stage 1) and then antegrade dissection and reentry (stage 2).

Retrograde techniques are initially learned by using septal collaterals and bypass grafts, which are safer and easier to cross (stage 3), followed by use of the more challenging (and risky) epicardial (and ipsilateral) collaterals (stage 4).

Many operators may initially or permanently choose to remain antegrade-only operators, given the rapid increase in complexity and risk associated with use of retrograde techniques. As long as they understand their strengths and limitations, whether an operator is antegrade-only or antegrade and retrograde is a matter of personal choice. With continued practice some operators who initially chose to do only antegrade techniques may elect to do retrograde procedures and vice versa.

13.3

Learning Chronic Total Occlusion Percutaneous Coronary Intervention: Fellowship and On-the-Job Training

Learning CTO PCI can be achieved either through a formal fellowship program or through on-the-job training ( Table 13.1 ). Most operators currently train for CTO PCI while practicing.

The advantages of formal fellowship training include the concentrated experience and exposure to large case volume and highly complex cases, prolonged direct working relationship with advanced CTO operators, and opportunity to get heavily involved in CTO PCI research. Disadvantages include the still developing catheterization and angioplasty skills (most fellowships are done after conclusion of the formal interventional training), and limited availability of dedicated fellowships for CTO PCI and other complex and higher risk procedures.

Both pathways can provide excellent training.

13.4

Learning Chronic Total Occlusion Percutaneous Coronary Intervention: Books, Internet, Meetings, Proctorships

The following tools can assist an interventionalist to evolve into a successful CTO operator:

• 1.

  Reading CTO-related literature (all interventional journals; Catheterization and Cardiovascular Interventions, Journal of Invasive Cardiology, Eurointervention, Circulation: Cardiovascular Interventions, and JACC Cardiovascular Interventions provide detailed articles on the technical and clinical aspects of CTO PCI).

• 2.

  Participating in online CTO-related education: this book provides links to several recorded CTO PCI cases on YouTube (can be searched at: www.ctomanual.org ). Also www.ctofundamentals.org , http://apcto.club/apcto-algorithm/ , and www.incathlab.com are outstanding websites providing basic to advanced CTO PCI education; they also provide online physician communities that regularly share cases and expertise. In some cases success may hinge on a nuance of technique that an operator may never have done before and may be aware of it only through a course, the Internet, or the literature.

• 3.

  Observing CTO interventions at experienced CTO PCI centers.

• 4.

  Attending CTO PCI courses and meetings (such as the CTO Academy at CRT, the Cardiovascular Research Foundation CTO Summit, the SCAI Annual Meeting, the Japan CTO Club, the Cardiovascular Innovations meeting, TCT, and the EuroCTO Club).

• 5.

  Getting proctored by experienced CTO interventionalists: on-the-job training is invaluable for learning CTO PCI techniques.

• 6.

  Practicing: as with any procedure, the more CTO interventions you do, the better CTO operator you become!

• 7.

  Working with another interventionalist during CTO PCI, if feasible, allows for real-time feedback and adaptation of the procedural plan.

13.5

Learning Chronic Total Occlusion Percutaneous Coronary Intervention: Where to Put Particular Emphasis

• 1.

  Meticulous procedural planning: understanding the CTO anatomy and the possible crossing strategies facilitates efficient and confident conversion within the hybrid algorithm ( Chapter 7 ).

• 2.

  Carefully selecting patients who are likely to benefit from CTO PCI, as outlined in Chapter 1 .

• 3.

  Focusing and practicing the basics of CTO PCI, as outlined in Chapter 2 .

• 4.

  Persistence: committing time and energy is required for CTO PCI. Per Dr. Bill Lombardi, one of fathers of CTO interventions in North America, “you either do CTO PCI, or you don’t–there is no such thing as trying.” In other words some CTO interventions can be challenging and demanding, but the key to success is persistence. With increasing experience the procedures become faster and success rates increase.

• 5.

  Being creative: every CTO is unique and may require a different, tailored, treatment approach (although an overall standardization of CTO PCI techniques, such as the hybrid approach, can facilitate planning as described in Chapter 7 ).

• 6.

  Learning from failures: unlike non-CTO interventions, CTO PCI failure is not uncommon, especially early in the learning curve. Failed procedures should not be a source of discouragement, but should rather stimulate constructive evaluation and learning. Discussing failed cases with other operators can be fruitful, as can be reattempting these cases with a proctor or referring them to more experienced centers. Knowing when to fail is also important: it is better to fail without complication than try too hard and have a (sometimes) catastrophic complication.

• 7.

  Publishing challenging or unique CTO PCI cases, or the overall outcomes of the CTO PCI program.

• 8.

  Keeping track of procedural outcomes, for example by creating a local CTO PCI database or by joining the Prospective Global Registry for the Study of Chronic Total Occlusion Percutaneous Coronary Interventions (PROGRESS-CTO, clinicaltrials.gov Identifier: NCT02061436 , www.progresscto.org ).

• 9.

  Participating in new studies on CTO interventions.

13.6

Creating a Chronic Total Occlusion Percutaneous Coronary Intervention Team

The importance of building a CTO team, procuring the necessary equipment, and implementing appropriate policies cannot be overemphasized, and consists of:

• 1.

  Staff education, including:

  • a.

    Lectures for cath lab staff on the indications and complexity of CTO PCI.

  • b.

    Educating the non-cath team about the process and outcomes of CTO PCI.

  • c.

    Identifying specific cath lab personnel champions who are:

    • –

      Interested in developing further expertise in CTO PCI.

    • –

      Interested in routinely being involved in CTO PCI cases (which helps in building experience and achieving excellent outcomes).

• 2.

  Obtaining the necessary infrastructure and equipment ( Chapter 2 , Table 2.1 ).

  • a.

    At least two cath lab rooms (so that emergencies can go to the second room if CTO PCI is performed in the first room).

  • b.

    Cardiac computed tomography and magnetic resonance imaging.

  • c.

    On site cardiac surgery.

• 3.

  Establishing CTO-specific protocols for:

  • a.

    Radiation (as described in detail in Chapter 10 ):

    • –

      Utilizing 6 to 7.5 frame-per-second fluoroscopy.

    • –

      Continuously monitoring radiation dose.

    • –

      Stopping the procedure if crossing has not been achieved after approximately 7–10 Gy air kerma dose.

    • –

      Following up patients who receive >5 Gy air kerma dose to detect any skin injury.

  • b.

    Anticoagulation:

    • –

      Repeating ACT every 30 min.

    • –

      Goal ACT >300 s for antegrade cases.

    • –

      Goal ACT >350 s for retrograde cases.

• 4.

  Establishing CTO days, which allows uninterrupted and concentrated focus on CTO PCI procedures: it is important for the operator to know that he/she has no other commitments for several hours, allowing prolonged treatment attempts if necessary. Moreover, dedicated CTO days can improve staff acceptance of starting a CTO program, facilitate visits by proctors or clinical specialists, and also allow referring cardiologists to visit.

• 5.

  Performing challenging cases as a team: having two interventionalists in the procedure improves the likelihood of success.

13.7