CTO PCI: Meeting the Challenge of a Distal Cap Bifurcation

By Emmanouil Brilakis, MD


The main challenge with chronic total occlusion (CTO) percutaneous coronary intervention (PCI) is crossing the lesion with a guidewire. This can be sometimes be challenging, but with use of contemporary equipment(1,2) and procedural strategies,(2,3) high success rates (often >90%) can be achieved.

The next challenge is to achieve recanalization of all occluded branches. CTOs often have side branches at the proximal or distal cap, and some of those branches may become occluded after CTO PCI, sometimes leading to periprocedural myocardial infarction or resulting in incomplete revascularization.

How can flow be restored in all branches adjacent to the CTO? The first step is to appreciate that such branches are present and determine that maintaining their patency is important. For example, although occlusion of acute marginal branches of the right coronary artery is often considered  inconsequential, it can often lead to acute myocardial infarction and/or ventricular arrhythmias. The second step is to devise a strategy for maintaining patency of all these branches, which can be challenging especially if subintimal dissection/re-entry techniques are used.

In this issue of the Journal of Invasive Cardiology, we present a case in which recanalization of a right coronary artery CTO succeeded into the right posterolateral branch, but antegrade wiring of the right posterior descending artery failed.(4) The retrograde approach was used to restore flow into the right posterior descending artery with an excellent final result.

Applying multiple procedural techniques in the same case requires experience with these techniques and rapid decision making to minimize the radiation and contrast administration; however, this additional investment of effort may provide optimal results.


  1. Garcia S, Abdullah S, Banerjee S, Brilakis ES. Chronic total occlusions: patient selection and overview of advanced techniques. Curr Cardiol Rep. 2013;15:334.
  2. Brilakis ES. Manual of Coronary Chronic Total Occlusion Interventions. A Step-By-Step Approach. Waltham, MA: Elsevier, 2013.
  3. Brilakis ES, Grantham JA, Rinfret S, et al. A percutaneous treatment algorithm for crossing coronary chronic total occlusions. JACC Cardiovasc Interv. 2012;5:367-379.
  4. Kotsia A, Christopoulos G, Brilakis ES. Use of the retrograde approach for preserving the distal bifurcation after antegrade crossing of a right coronary artery chronic total occlusion. J Invasive Cardiol. 2014;26:E48-E49.


This entry was posted in Uncategorized and tagged , , . Bookmark the permalink.

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out /  Change )

Google photo

You are commenting using your Google account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

Connecting to %s