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Focus article

European perspective in the recanalisation of Chronic Total Occlusions (CTO): consensus document from the EuroCTO Club

1. Royal Brompton Hospital and Imperial College, London, United Kingdom; 2. Klinikum Darmstadt, Darmstadt, Germany; 3. Thoraxcentre, Erasmus, Medical Center, Rotterdam, The Netherlands; 4. Ospedale Ferrarotto, University of Catania, Catania, Italy; 5. Heart Centre, Bad Krozingen, Germany; 6. Jagellonian University, Cracow, Poland; 7. Centre Cardiologique du Nord, Saint-Denis, France; 8. Institut Hospitalier Jacque Cartier, Massy, France; 9. Hamburg University Cardiovascular Center, MVZ Prof. Mathey, Prof. Schofer GmbH, Hamburg, Germany; 10. Catharina Ziekenhuis, Eindhoven, The Netherlands; 11. Frankfurt, Germany; 12. Ospedale di Mirano, Venice, Italy; 13. Toulouse, France; 14. Centro Cuore Columbus and San Raffaele Hospital, Milan, Italy; 15. Univ. of Leicester, Leicester, United Kingdom; 16. Bad Soden, Germany

Within the cardiology community there continues to be confusion regarding the indications for percutaneous coronary interventions (PCI) in patients with chronic total occlusion (CTO) and scepticism with regard to the ultimate impact revascularisation has on patient outcomes. It is not surprising, therefore, that most interventional cardiologists try to avoid these potentially long procedures that can be costly and expose the operator to higher radiation doses1,2 and, with success rates remained unchanged in the last years, perceived as insufficient to justify the effort involved. The procedural complexity of CTO angioplasty and the lack of familiarity with new equipment and techniques often prompts half-hearted and prematurely aborted attempts at PCI, leading to physician and patient frustration. A recent analysis from a NHLBI database even showed a decrease of attempted PCIs in CTOs from 9.4 to 5.7% between 1997 to 20043. Consequently, patients with single vessel disease and chronically occluded vessels are often managed medically regardless of the severity of symptoms and extent of ischaemia, and those with multivessel disease with a CTO are referred for bypass graft surgery even if the other lesions are ideal suited for PCI4-7. As a reaction to this prevailing attitude, experienced European interventionists have recently established the EuroCTO Club, modelled on similar initiatives in Japan and the USA, whereby members share their experience both within the group and with the interventional and general cardiology communities at large.

The aim of the EuroCTO Club is to promote clinical excellence through training and quality control as well as fostering research and technical development in the field of CTO recanalisation. The current paper is an essential part of this strategy: we do not wish to challenge or overcome other recent comprehensive reviews of this broad subject8-12, but rather, our aim is to highlight misconceptions in clinical indication, outdated technical choices, inadequacies in operator training and centre qualifications and equipment which limit a more widespread application of percutaneous techniques for recanalisation of CTO in Europe and impair the consistent achievement of the high success rates possible with contemporary techniques.

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