Although chronic total occlusion (CTO) percutaneous coronary intervention (PCI) can be a very challenging procedure, it can be performed with a high success rate without compromising safety . What are the ingredients of success? Richard St. John in his 3.5 minute TED talk outlines 8 secrets to success in life that also nicely apply to CTO PCI ( https://www.ted.com/talks/richard_st_john_s_8_secrets_of_success?language=en ):
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Passion . CTO PCI cannot be forced upon an operator and a program; it should be the result of a strong desire to expand the interventional capabilities of the program in order to better serve patients. Operators should have a strong conviction of the benefits of CTO PCI and a strong drive that will allow them to advance in spite of the challenges and disappointments of the learning curve.
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Work . Successfully performing CTO PCI requires both individual skills and the proper program setup. There are multiple opportunities for education currently, with several CTO PCI books, journal articles, and online resources ( www.ctofundamentals.org ). There are also several beginner and advanced courses developed by industry and cardiology societies, such as the Society for Cardiac Angiography and Interventions, as well as proctoring programs allowing less experienced interventionalists to work with expert CTO operators in their cardiac catheterization laboratory. Setting up a program involves education of the cardiac catheterization laboratory staff as well as the administration, development of procedural guidelines, and implementation of a quality control program either locally or by participation in an established ongoing CTO PCI registry, such as the Prospective Global Registry for the Study of Chronic Total Occlusion Intervention (Progress CTO, NCT02061436) .
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Focus . Although we all want to do more and more, developing a CTO PCI program requires significant investment in time and effort, which may be hard to achieve if one also simultaneously attempts to develop a structural program, or a peripheral interventions program, or another type of program. Although not applicable to everyone, the quote “Jack of all trades, master of none” likely applies to CTO PCI, especially during the early stages of program development.
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Persist . Frustration and disappointment are certain to come to operators who systematically perform CTO PCI, even the best in the world. Some procedures will be long, requiring use of several techniques and many pieces of equipment. Some procedures will fail. Some patients will develop complications . Successful operators use these experiences in a constructive way as tools for learning and improvement.
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Ideas . Due to its difficulty and diversity, CTO PCI offers unlimited opportunities for improvising and problem solving. This is at the core of the hybrid approach to CTO PCI ( Fig. 1 ) , which advocates early change during the same procedure from a failure mode to another approach. The cycle is repeated again and again until success is achieved (or the radiation dose or contrast dose limit is reached). Approaching each challenge as an opportunity rather than as a threat can lead to great insights and innovations, which can then be shared with the interventional community, helping others and inspiring them to continue to find better and simpler solutions.
