A complex dissected chronic occlusion: targeted balloon dilatation of false lumen to access true lumen, combined localized subintimal tracking and re-entry, parallel wire, contralateral injection and a useful antegrade lumen re-entry technique

Chronic total occlusion (CTO) angioplasty is one of the most challenging procedures remaining for the interventional operator. Recanalizing CTOs can improve exercise capacity, symptoms, left ventricular function and possibly reduce mortality. Multiple strategies such as escalating wire, parallel wire, see-saw, contralateral injection, subintimal tracking and re-entry (STAR), retrograde wire techniques (controlled antegrade retrograde subintimal tracking, CART), reverse CART, confluent balloon, rendezvous in coronary, and other techniques have all been described. Selection of the most appropriate approach is based on assessment of vessel course, length of occluded segment, presence of bridging collaterals, presence of bifurcating side branches at the occlusion site, and other variables. Today, with significant operator expertise and the use of available techniques, the literature reports a 50-95% success rate for recanalizing CTOs.