CTO Corner

How to Start a CTO Program

You have witnessed a recent explosion in the popularity of chronic total occlusion interventions. You also have seen some amazing cases and are now ready and excited to start your own CTO program. But, what is the next step?

Although “on the job” training was how many of us learned to do CTO PCI because of a lack of better alternatives several years ago, this is definitely not the best way to proceed currently. In 2015, starting a successful CTO program is best achieved through a systematic effort that addresses four components: 1) the operator; 2) the cardiac catheterization laboratory; 3) the administration; and 4) the referring physicians and patients.

1. Operator

The first step in CTO PCI learning involves understanding the techniques and becoming familiar with the equipment armamentarium and nomenclature. This can be achieved by reading journal articles such as those in Catheterization and Cardiovascular Interventions, the Journal of Invasive Cardiology and JACC: Cardiovascular Interventions; books such as the Manual of Coronary Chronic Total Occlusion Intervention; online resources such as ctofundamentals.org; and through didactic courses such as the Cardiovascular Research Foundation’s Chronic Total Occlusion Summit and the Society for Cardiac Angiography and Interventions Chronic Total Occlusion regional training series.

Not everything will make sense the first time around, as understanding the underlying principles, indications and techniques is an incremental process. This is especially true for antegrade dissection/re-entry and for the retrograde approach, which are fundamentally different from standard PCI techniques. Moreover, gaining clear understanding of the indications for CTO PCI is key (see: The Why and How of CTO Interventions in the Cardiology Today’s Intervention January/February 2012 issue).

Emmanouil S. Brilakis, MD, PhD

Emmanouil S. Brilakis

The second step is participating in a live CTO course (such as the Chronic Total Occlusion Summit or various regional courses). This is often a key motivator for starting a CTO program — seeing is believing. Cases are performed by experienced CTO operators in an interactive fashion with the participants and the panel. This is an outstanding way to observe live “troubleshooting” and interact with experts in the field.

The third step is proctoring, which involves performing CTO PCI in the presence of an experienced CTO operator who provides guidance and support. This step presupposes successful completion of the first two steps: the operator who “does not know what a Corsair catheter is” or “does not understand the term ‘reverse CART’” is not ready to do CTO PCI. Proctoring is especially important the first time one of the more demanding CTO crossing techniques, such as antegrade dissection/re-entry and retrograde, is performed and makes the procedure safer and more efficient. Moreover, it helps establish a network that can be used for continued support and advice on subsequent cases.

2. Catheterization Laboratory

Educating the cath lab personnel helps alleviate concerns, as well as builds excitement and consensus about the procedure. The necessary equipment is obtained and organized in a “CTO cart” for easy retrieval during cases. Not having the right equipment can be highly frustrating and also may decrease the likelihood of successfully completing the cases. Emphasis is given on the need to carefully monitor radiation exposure (announcing the air kerma radiation dose with each Gray) and monitoring anticoagulation (usually measuring activated clotting time every 30 minutes). It is ideal to identify one to two technicians with interest in CTO PCI who are motivated to learn the procedure and gain additional experience. It also is best to designate “CTO days,” allowing for intensive and uninterrupted focus on these often complex procedures and for proctoring.

3. Administration

Securing support from the hospital administration is key for the success of a CTO PCI program, especially early in the learning curve, when success rates may not be as high as they will be later on. Moreover, procedures are likely to take longer to complete in the beginning and equipment utilization will be higher compared with non-CTO PCI. Points that can help convince administration on the value of CTO PCI include providing data that CTO PCI can actually provide a positive contribution margin and highlighting the importance of the “halo” effect, assuming that if an institution is good at CTO PCI that it also will be good at everything else. When an institution gains recognition for doing CTO PCI, referrals of non-CTO complex cases also increase as does the institution’s reputation, both with referring physicians and with patients.

4. Referring Physicians and Patients

It is not infrequent for noninvasive and even some invasive cardiologists to have a negative perception regarding the feasibility and potential risks and benefits of CTO PCI. Changing this perception is possible, but requires time and persistence.

Education on what we know as well as what we don’t know about CTO PCI can go a long way. Clarifying that CTO PCI will not be inappropriate as long as the patient has symptoms and is receiving two antianginal medications can help alleviate concerns in the current era of appropriateness use criteria. Similarly, it is important to educate the patients about the risks and benefits of CTO PCI. Patients with CTOs are often quite savvy and do extensive online search before choosing a treating physician.

With regard to promoting the CTO program, it is best to go slow. Projecting oneself as a CTO PCI expert and tackling very complex occlusions before reaching maturity can backfire: It is quite frustrating for referring MDs to see repeat failure of cases they referred. It is best to work quietly behind the scene building the CTO PCI skills before aggressively promoting the program. At the same time, it is important to share all successes with colleagues, effectively “re-training” them on what can be achieved with CTO PCI.

Keys for Success

“Just do it” is clearly not the best way to start a CTO program. Careful planning, methodical learning and staged implementation are keys for success. In 2015, there are ample resources for CTO PCI training and continued support. Taking advantage of them can lead to early — and, even more important, lasting — success.

References:
Brilakis ES. Manual of Coronary Chronic Total Occlusion Interventions. A Step-By-Step Approach. Waltham, MA: Elsevier; 2013.
Karmpaliotis D, et al. Catheter Cardiovasc Interv. 2013;82:1-8.
For more information:
Emmanouil S. Brilakis, MD, PhD, is the director of the cardiac catheterization laboratory at the VA North Texas Health Care System, Dallas, and is associate professor of medicine at the University of Texas Southwestern Medical Center, Dallas. He also is a Cardiology Today’s Intervention Editorial Board member. He can be reached at Dallas VA Medical Center (111A), 4500 S. Lancaster Road, Dallas, TX 75216; email: esbrilakis@gmail.com.

Disclosure: Brilakis reports receiving honoraria/consultant fees from Abbott Vascular, Asahi, Boston Scientific, Elsevier, Janssen Pharmaceuticals, Sanofi, Somahlution, St. Jude Medical and Terumo; research support from Guerbet; and his spouse is an employee of Medtronic.

You have witnessed a recent explosion in the popularity of chronic total occlusion interventions. You also have seen some amazing cases and are now ready and excited to start your own CTO program. But, what is the next step?

Although “on the job” training was how many of us learned to do CTO PCI because of a lack of better alternatives several years ago, this is definitely not the best way to proceed currently. In 2015, starting a successful CTO program is best achieved through a systematic effort that addresses four components: 1) the operator; 2) the cardiac catheterization laboratory; 3) the administration; and 4) the referring physicians and patients.

1. Operator

The first step in CTO PCI learning involves understanding the techniques and becoming familiar with the equipment armamentarium and nomenclature. This can be achieved by reading journal articles such as those in Catheterization and Cardiovascular Interventions, the Journal of Invasive Cardiology and JACC: Cardiovascular Interventions; books such as the Manual of Coronary Chronic Total Occlusion Intervention; online resources such as ctofundamentals.org; and through didactic courses such as the Cardiovascular Research Foundation’s Chronic Total Occlusion Summit and the Society for Cardiac Angiography and Interventions Chronic Total Occlusion regional training series.

Not everything will make sense the first time around, as understanding the underlying principles, indications and techniques is an incremental process. This is especially true for antegrade dissection/re-entry and for the retrograde approach, which are fundamentally different from standard PCI techniques. Moreover, gaining clear understanding of the indications for CTO PCI is key (see: The Why and How of CTO Interventions in the Cardiology Today’s Intervention January/February 2012 issue).

Emmanouil S. Brilakis, MD, PhD

Emmanouil S. Brilakis

The second step is participating in a live CTO course (such as the Chronic Total Occlusion Summit or various regional courses). This is often a key motivator for starting a CTO program — seeing is believing. Cases are performed by experienced CTO operators in an interactive fashion with the participants and the panel. This is an outstanding way to observe live “troubleshooting” and interact with experts in the field.

The third step is proctoring, which involves performing CTO PCI in the presence of an experienced CTO operator who provides guidance and support. This step presupposes successful completion of the first two steps: the operator who “does not know what a Corsair catheter is” or “does not understand the term ‘reverse CART’” is not ready to do CTO PCI. Proctoring is especially important the first time one of the more demanding CTO crossing techniques, such as antegrade dissection/re-entry and retrograde, is performed and makes the procedure safer and more efficient. Moreover, it helps establish a network that can be used for continued support and advice on subsequent cases.

2. Catheterization Laboratory

Educating the cath lab personnel helps alleviate concerns, as well as builds excitement and consensus about the procedure. The necessary equipment is obtained and organized in a “CTO cart” for easy retrieval during cases. Not having the right equipment can be highly frustrating and also may decrease the likelihood of successfully completing the cases. Emphasis is given on the need to carefully monitor radiation exposure (announcing the air kerma radiation dose with each Gray) and monitoring anticoagulation (usually measuring activated clotting time every 30 minutes). It is ideal to identify one to two technicians with interest in CTO PCI who are motivated to learn the procedure and gain additional experience. It also is best to designate “CTO days,” allowing for intensive and uninterrupted focus on these often complex procedures and for proctoring.

3. Administration

Securing support from the hospital administration is key for the success of a CTO PCI program, especially early in the learning curve, when success rates may not be as high as they will be later on. Moreover, procedures are likely to take longer to complete in the beginning and equipment utilization will be higher compared with non-CTO PCI. Points that can help convince administration on the value of CTO PCI include providing data that CTO PCI can actually provide a positive contribution margin and highlighting the importance of the “halo” effect, assuming that if an institution is good at CTO PCI that it also will be good at everything else. When an institution gains recognition for doing CTO PCI, referrals of non-CTO complex cases also increase as does the institution’s reputation, both with referring physicians and with patients.

4. Referring Physicians and Patients

It is not infrequent for noninvasive and even some invasive cardiologists to have a negative perception regarding the feasibility and potential risks and benefits of CTO PCI. Changing this perception is possible, but requires time and persistence.

Education on what we know as well as what we don’t know about CTO PCI can go a long way. Clarifying that CTO PCI will not be inappropriate as long as the patient has symptoms and is receiving two antianginal medications can help alleviate concerns in the current era of appropriateness use criteria. Similarly, it is important to educate the patients about the risks and benefits of CTO PCI. Patients with CTOs are often quite savvy and do extensive online search before choosing a treating physician.

With regard to promoting the CTO program, it is best to go slow. Projecting oneself as a CTO PCI expert and tackling very complex occlusions before reaching maturity can backfire: It is quite frustrating for referring MDs to see repeat failure of cases they referred. It is best to work quietly behind the scene building the CTO PCI skills before aggressively promoting the program. At the same time, it is important to share all successes with colleagues, effectively “re-training” them on what can be achieved with CTO PCI.

Keys for Success

“Just do it” is clearly not the best way to start a CTO program. Careful planning, methodical learning and staged implementation are keys for success. In 2015, there are ample resources for CTO PCI training and continued support. Taking advantage of them can lead to early — and, even more important, lasting — success.

References:
Brilakis ES. Manual of Coronary Chronic Total Occlusion Interventions. A Step-By-Step Approach. Waltham, MA: Elsevier; 2013.
Karmpaliotis D, et al. Catheter Cardiovasc Interv. 2013;82:1-8.
For more information:
Emmanouil S. Brilakis, MD, PhD, is the director of the cardiac catheterization laboratory at the VA North Texas Health Care System, Dallas, and is associate professor of medicine at the University of Texas Southwestern Medical Center, Dallas. He also is a Cardiology Today’s Intervention Editorial Board member. He can be reached at Dallas VA Medical Center (111A), 4500 S. Lancaster Road, Dallas, TX 75216; email: esbrilakis@gmail.com.

Disclosure: Brilakis reports receiving honoraria/consultant fees from Abbott Vascular, Asahi, Boston Scientific, Elsevier, Janssen Pharmaceuticals, Sanofi, Somahlution, St. Jude Medical and Terumo; research support from Guerbet; and his spouse is an employee of Medtronic.