Applying the Lessons of CTO to Complex PCI

At a Glance:

●  Chronic total occlusion (CTO) is a highly specialized area of percutaneous coronary intervention (PCI), requiring a high level of judgment, skill, and the use of advanced techniques.

●  Many complex PCI strategies can translate to other PCI spaces, but operators may not be as familiar with these approaches or how to apply them.

●  CTO Plus and meetings like it offer a chance for experts to share their strategies and show how they can be implemented safely, effectively, and appropriately.


Percutaneous coronary intervention (PCI) has revolutionized how we treat coronary artery disease (CAD). This minimally invasive strategy—using catheters to access the coronary arteries through blood vessels in the groin, arm, or neck—offers a safe, effective alternative to open surgery. Chronic total occlusions (CTOs)—when coronary arteries become completely blocked—represent the most complex and challenging cases to treat with PCI, requiring both the highest level of operator skill and the latest strategies and techniques. But although many PCI advances and strategies were developed specifically for CTOs, they offer tremendous benefits for other areas of complex CAD treatment.

To make these insights available to all specialists working with high-risk CAD patients (known as Complex Higher-Risk [and Indicated] Patients, or CHIP), the interventional cardiology community regularly comes together through workshops and large meetings like CTO Plus.

Terms to Know

What is CAD?

Coronary artery disease (CAD) is a narrowing or blockage in the coronary arteries, which supply blood to the heart itself. This means the heart cannot get enough blood and oxygen to function properly. CAD can lead to severe symptoms like heart attacks and heart failure and is often fatal.

What is CTO?

Chronic total occlusion (CTO) occurs when a coronary artery becomes completely blocked. This life-threatening condition requires a very specific combination of operator skill, advanced imaging, and specialized technology to safely treat.

What is PCI?

Percutaneous coronary intervention (PCI) is a minimally invasive procedure that uses catheters to access the coronary arteries through a large blood vessel, usually in the groin. PCI allows doctors to treat CAD without surgery and offers shorter hospital stays, faster recovery times, and a lower risk of complications.

CTO Plus

The 2022 CTO Plus: Complex CTO and Higher Risk PCI course will be held in person February 24–25 at the New York Marriott Marquis. The largest meeting of its kind in the U.S., CTO Plus brings together the most skilled operators working with complex PCI techniques to discuss the latest advances and strategies for taking care of higher-risk patients. In addition to data presentation, discussions, and live cases, this year’s CTO Plus features an expanded program that includes complex PCI topics.

A Tradition of Collaboration

“[CTO Plus] started out as a workshop in 2004, with 50 invited faculty,” says Jeffrey Moses, MD, a CTO Plus course director and leading CTO specialist at Columbia University Irving Medical Center. “Now it’s by far the largest of its kind in the United States—and one of the largest in the world.”

Now in its 18th year, CTO Plus (formerly CTO Summit) was initially developed with the Cardiovascular Research Foundation (CRF) as a way to share the latest advances between leading experts at a time when strategies and techniques varied greatly across practices, institutions, and regions.

“One of the goals at the time was to address ‘the tower of Babel’ of total occlusions,” remembers Dr. Moses. “First, different operators had their own idiosyncratic ways of doing them and it was very diverse. Then it coalesced into a more national or regional basis—in other words, this North American style, a European style, and an East Asian style.

“I remember saying, ‘I hope that over time we have a convergence toward a universal approach to it.’ And recently, there's been collaboration toward developing an algorithm that reflects worldwide input. So to me, it's the realization of the dream: defining this space and having specific approaches to specific problems that can guide the operators to success,” says Dr. Moses.

Bringing the Message to a Broader Audience

But this year marks an important expansion: targeting a broader audience of PCI specialists and teams that can benefit from employing elements for CTO strategies in their own spaces.

“This is an important challenge,” says Dr. Moses. “CTOs are a specialization. We recommend there be a few operators in any group who are really focused on CTOs because volume and experience count for a lot. But because of that, non-CTO operators may not be acquainted with these techniques, even though they’d be supremely helpful to them.

“We're trying to broaden the audience here so that even if they don't do CTOs, they will still have the techniques at their command for patients they do perform procedures on,” says Dr. Moses.

CTO Plus offers clinicians and staff working with CTO—and complex PCI—a chance to learn about these new advances and see how they might help improve outcomes in their own high-risk patients.

“Over the years, we've understood that a lot of the skills you learn in the CTO space are actually transferable to treating other patients,” says Margaret McEntegart, MD, a CTO Plus course director and interventional cardiologist with Columbia. “So the idea is to cover CTO almost like an outreach: to involve more people who are around the periphery of CTO and try to bridge the community toward them. We want to encourage them to explore the more complicated end of PCI work that ultimately leads into CTO PCI.

“I think one of the great things CTO Plus will focus on this year is catering to a wider population and more holistic treatment of the patient, rather than just focusing on CTO,“ says Dr. McEntegart.

This holistic approach also encourages a broader discussion of both how and when to apply these strategies. Seasoned experts can provide valuable insight into how they approach difficult CTO cases.

“It’s incredibly important to discuss clinical indications for complex procedures,” states Ajay J. Kirtane, MD, SM, a CTO Plus course director and interventional cardiologist with Columbia. “Beyond discussion of ‘how to’ treat, there has to be a clear understanding of ‘when to and when not to’ treat as well. We have really tailored this meeting to address these important issues in complex PCI.”

Exploring All Aspects of Complex PCI

CTO Plus has also expanded to include a wider range of complex PCI topics, including intravascular imaging and physiology, calcified coronary disease, left main/bifurcation lesions, diffuse disease (surgical turndowns), and mechanical circulatory support in CHIP patients.

The course will continue to present live cases in a workshop setting, providing attendees—both in-person and online—the opportunity to learn from some of the best interventionalists in the world.

“I think the target audience is people like me, 10 years ago,” says Dr. McEntegart. “When I finished my fellowship and went back to the UK, I set up the CTO and complex PCI service. I went to these CTO Summit meetings: I sat in the audience, I watched the live cases—I really soaked it all in.

“The course pulls in young, aspirational interventional cardiologists and provides them with access to this amazing range of knowledge and expertise. When they go back to where they work, it really helps drive their services forward.

CTO Plus highlights the rapid progress PCI has made toward becoming an equivalent strategy to traditional bypass surgery. “There's been this goal for PCI to become equivalent to bypass surgery—we've really been working toward that over the last 30 years,” explains Dr. McEntegart. “And what we can see from the evidence for PCI is that we're tantalizingly close to getting the same kind of outcomes you can get in bypass surgery.

“At CTO Plus, we're going to put a lot of focus on that precision approach: optimizing the result for the patient and making that final push toward the two therapies being equivalent.”.

Putting the Pieces Together

CTO Plus explores more than the cutting edge for devices, techniques, and adjunct imaging—it provides insight into how these advances are changing the way we look at PCI. “There have been all sorts of ongoing developments with very CTO-specific technologies, which are slowly coming through,” notes Dr. McEntegart. “I think in the last two years, there have been dramatic developments in our understanding about imaging in the complex PCI space and around the area of calcium and the coronary artery.”

For example, procedures like coronary atherectomy and intravascular lithotripsy have expanded options for treating calcium and the coronary arteries. “But beyond being transformational technologies, they have encouraged operators to focus on very precisely and quantifiably assessing calcium and the coronary arteries,” says Dr. McEntegart. “Once you’ve assessed the calcium, you can decide which of the array of available devices is best suited for that individual patient—and you can use imaging to confirm that you've done what you need to do before you put the stent in.

“That’s a real benefit of events like CTO Plus—putting all these pieces together. A disruptive technology doesn’t only disrupt the space in terms of people using that technology, it actually drives understanding of what you're dealing with. People pay more attention to the problem because now they have specific technologies to deal with it.”

A Personalized Approach

For clinicians and staff working with CTO and complex PCI, CTO Plus represents a unique opportunity to learn about new advances and see how they might help improve outcomes in their own CHIP patients.

“There are evolving techniques and technologies that will be discussed,” says Dr. Moses. “And the emphasis is certainly on cases and understanding how to do them. But we're also trying to get a very personalized approach where the experts pull back the curtain and really discuss their points of view on many issues.

“It's not just presentation of data, it’s about the interpretation of the data. We're trying to encourage individuals to really give their unvarnished opinion. You can get lectures about data anywhere. But getting access to this concentration of expertise—having these experts available to you, seeing them interact, and being able to interact with them—is a truly unique aspect of this course.”

Learn more about Complex Coronary Care at Columbia

Learn more about CTO Plus: Complex CTO and Higher Risk PCI