Having expressed an interest in learning these skills and introducing a CTO PCI program (and having the support of your institution), there are a few more steps prior to undertaking your first case. We would recommend background reading around the field of CTO PCI (potentially with a book such as this!), essentially immersing you in the subject and becoming familiar with terminology and techniques. Co-incident with this reading, various online resources exist to reinforce your learning. One such resource (ctofundamentals.org) offers step-wise lectures and tutorials on various aspects of CTO PCI and allows continuous feedback via regular self-assessment tests. Also, once your program is established, this is a worthwhile resource for advice and suggestions to help overcome difficult cases and, importantly, for support and help following failure or complications. Attendance at a dedicated CTO course or symposium (ideally involving live cases) will go some way to increasing your awareness of what is possible in this field. In anticipation of your program starting (and as an early team building exercise), it is a good idea to fund your desired CTO PCI team (nurses, technicians, etc) to also attend.

Initial contact with your proctor will involve review of cases and also they will provide a “shopping list” of necessary equipment. Although equipment is covered in the next chapter, the only recommendation we would make is organizing CTO-specific equipment in an easily accessed space. At our institution we use a mobile cart that can be wheeled into whichever laboratory is being used for CTO PCI (Fig. 2.2).

During the initial proctored cases at your institution, this is an ideal opportunity to review further cases for their suitability as your first solo cases. With regard to case planning, we have found the use of CTO Planning Forms to be invaluable (see Fig. 2.3). These follow the hybrid algorithm [4] and mean that, whoever is performing the CTO PCI, a clear plan of action is delineated. Although there are no hard and fast rules, it is advisable to start slow with one or, at most, two CTO cases scheduled on your first few dedicated CTO PCI days. On each day, ensure the staff is aware of the planned procedure (antegrade, retrograde, etc). After each dedicated CTO PCI day, review the cases undertaken that day. Evaluating each step in a case is important, particularly in unsuccessful cases where understanding the mode of failure may predict future success. If unsure how to overcome difficulties, discussion with your proctor or use of one of the online resources may obtain strategies and solutions to surmount these obstacles. Once your program is established, it can be useful to connect with other CTO PCI practitioners in your area. Informal dinner meetings are an ideal forum to show planned cases and obtain opinions as to potential strategies. Also, after failures or complications, these meetings are a great way of educating your colleagues of potential pitfalls. Finally, by collating your resources, they are also an excellent mechanism for undertaking research and evaluating outcomes in this field.