Possibly the most important consideration in CTO PCI is “why do it at all?” To understand when and where PCI is appropriate is vital to the success of the CTO program. It is important that any CTO Interventionalist be well versed in the data both supporting and refuting CTO PCI, as discussed in Chap. 1. It is usually not enough to be able to perform the procedure. The new operator should be thoroughly familiar with the current and historic literature regarding medical management, surgery, completeness of revascularization, ischemia-driven therapy, long term outcomes, and current indications for CTO PCI. In this day of increasing scrutiny, there is a strong need to be aware of Appropriate Use Criteria (AUC) and how they apply to the CTO PCI practice. “Because it’s there” might have been a good enough reason for George Mallory to attempt to climb Mount Everest, it is not a good enough reason to perform CTO PCI.

CTO PCI is difficult. If it were easy, Interventionalists would have always done it and there never would have been any issues. As a result of its difficulty, there will be many times when the new operator will be unsuccessful and, unfortunately, will encounter complications. As such, any operator contemplating in starting to perform advanced CTO PCI should ask him- or herself several questions: Is this the right time in my career for me to be doing this? Do I have enough experience as an Interventionalist to take this on? Will I have the time, ability, volume, and commitment to do this correctly? Am I doing this for the right reasons? Is this about making patients better, or is this about me? Those questions are of paramount importance.

CTO PCI is not the same as standard PCI. The CTO operator will be approaching lesions in ways that were taught to be avoided. Much of the equipment, terminology, and techniques are unfamiliar to even the most experienced Interventionalists. Even if someone has performed thousands of cases in a career, CTO PCI will still need to be approached with a novice perspective. For this reason, it is imperative that he or she educate him/herself though reading. Textbooks such as this one help explain the concepts. We also encourage the new operator to use the Internet. The CTO community has an educational website, CTOFundamentals.org, which has a series of lectures which cover all of the basics. Once the didactic sessions are completed, the operator is invited to join the online community where cases are discussed, new information is shared, and questions can be asked. Meetings are also a great source of education. All of the large meetings have CTO PCI specific sessions. There are meetings specific to CTO PCI including those put on by SCAI as well as CRF’s CTO Summit. Attending a course (or more than one) is strongly advocated. Currently there are several industry sponsored CTO courses throughout the year. These are small, live courses where experienced CTO PCI operators do cases on site and interact directly with the attendees in dynamic discussions illustrating all aspects of CTO PCI.