Putting It All Together: The Hybrid Approach

The optimal approach to chronic total occlusion (CTO) percutaneous coronary intervention (PCI) continues to evolve. Although various CTO crossing techniques have been developed (antegrade wire escalation; antegrade dissection/reentry; and retrograde, as described in Chapter 4, Chapter 5, Chapter 6 ), there are different schools of thought about the relative merits and priority of each of those approaches.

In January 2011 several high-volume CTO operators convened in a workshop that took place in Bellingham, Washington and created a consensus algorithmic approach about how to optimally approach CTO crossing. This approach, named the hybrid approach to CTO PCI ( Fig. 7.1 ), focuses on opening the occluded vessel, using all available techniques (antegrade, retrograde, true-to-true lumen crossing, or reentry), tailored to the specific case in the safest and most effective and efficient way.

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Overview of the hybrid chronic total occlusion crossing algorithm.

The main principle behind the hybrid approach is that operators should master all of the skill sets of CTO PCI and be able to alternate between these techniques during the same CTO PCI procedure to recanalize the CTO. The goal has been to demystify the procedure by breaking down its various components and gaining in-depth understanding of the principles underlying each technique, making it reproducible and teachable, and thus available to the broader interventional community. The hybrid approach has been used in a large number of cases in both the United States and Europe with high success rates, and is also useful in learning CTO PCI in a stepwise fashion.