Many interventional cardiologists would not attempt to revascularize a coronary chronic total occlusion (CTO) but would not hesitate to treat the same vessel if it were an 80% lesion. Why?

In this editorial discussion, our international panel of experts addresses the indications for CTO revascularization and the criteria for patient selection, including the role of noninvasive imaging and MRI, perceptions and misconceptions based on insight from the SYNTAX, OAT, and FAME trials, as well as ACC appropriateness criteria. From a practical standpoint, Drs Kandzari, Di Mario, Moses, and Werner offer pointers on technique and best practice, including selection of equipment and approaches, how best to establish a CTO program, and the likelihood of ever seeing a clinical randomized trial that would pit medical therapy vs PCI for the treatment of CTOs.