July 01, 2016
4 min read

The Symphony of CTO PCI

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“Ars longa, vita brevis.”

— Hippocrates

Symphony is a word derived from Greek as the composite of syn- (together) and phone (voice or sound). It is the harmonious combination of sounds, an elaborate instrumental composition, an instrumental piece usually performed by a large orchestra composed of string, wind and percussion instruments.

Chronic total occlusion PCI also is a symphony, performed by many participants: the patient; the cath lab team, including technicians, nurses and physicians; the administration; the medical device industry; and many others. However, unlike music symphony, CTO PCI does not follow a prewritten script, although it uses elements from various techniques, blended (hopefully, harmoniously) into a unique combination, every single time. Such elements include a thorough, detailed preparation for the procedure by reviewing the angiogram and creating a procedural “plan of attack.” This also includes implementation of strategies that facilitate success, such as use of supportive guide catheters, dual injection, and use of an over-the-wire system for both guidewire support and exchanges. More often than not, use of simple and basic techniques can have the most powerful effect on the outcome of the procedure.

An ‘Improvisational Symphony’

In essence, CTO PCI is an improvisational symphony. Yet, improvisation does not mean lack of preparation. In contrast, many people have been preparing for a long time to perform each procedure. The cath lab team has prepared by learning the basics of intervention as well as advanced techniques, by reading, attending meetings, talking to other teams, performing procedures, devising techniques, and sometimes writing reports and manuscripts. Administration has prepared by creating the necessary infrastructure and environment for the procedure to be feasible and successful. Industry has prepared by developing specialized devices for CTO PCI, testing such devices and continually improving them. And the patient has prepared to be the “patient” and allow the medical team to do the best they can.

Emmanouil S. Brilakis

Despite improvements in equipment and techniques, the outcomes of CTO PCI can be uncertain for prolonged periods of time. Many procedures may be failing for hours before success is finally achieved, or sometimes not achieved. How can one maintain the focus and faith in success, even when odds for success appear to be slim and declining? How can rational thinking continue, without taking excessive risks and without allowing fatigue and/or frustration to impair judgement and careful catheter and wire manipulations? This is in part why CTO PCI remains to large extent “art,” similar to music.

Change, Persistence Are Key Elements

Akin to musicians performing with the orchestra, good understanding and communication between the cath lab team members is an art critical for CTO PCI to be successful. Having multiple minds to think about the possible next steps and multiple eyes to assess progress can make the procedure both safer and more effective. Achieving the right balance between control and openness is key, as too much control can stifle creativity and problem-solving, whereas too much lightness can lead to oversights and increase the risk of the procedure. Mutual respect and open lines of communication can go a long way.

A basic principle of contemporary CTO PCI is “change,” ie, change of approach when the approach used is not succeeding. Deciding when to change is an art: Too short of an attempt may just miss a success about to be achieved, whereas attempts that take too long may “burn up” radiation and contrast, not allowing other, potentially more fruitful, strategies to be implemented. Deciding what to change into also is an art: Should the angiographic view be adjusted? Should contrast be injected? Should the next step be retrograde, antegrade dissection/re-entry, or perhaps just a change of a guidewire, the guidewire shape or a microcatheter? Most times, there is no right or wrong answer, and there are innumerable possible combinations.


Persistence is a key ingredient of the art of CTO PCI, as is meticulous attention to technique and frugality in use of radiation and contrast. In the past, reaching high doses of radiation was the main limiting factor. Today, with increasing awareness of the adverse effects of radiation, use of low-frame-rate fluoroscopy and increasing deployment of newer-generation, low-dose X-ray machines, the radiation limit is infrequently reached and contrast volume becomes more often the limiting factor. Continuous attention to radiation protection is an art as it is science, hopefully an internalized art that becomes second nature and does not require conscious attention, similar to eating or brushing our teeth.

Improving the ‘Art’ of CTO PCI

Perhaps, in the future, more advanced equipment and techniques will decrease the “art component” of CTO PCI, simplify it and render it more standardized. Perhaps a novel tool will self-orient and dig through and recanalize every single occlusion in an automated “fool-proof” way.

However, we are not there yet. We still need to learn and improve the “art” of CTO PCI. And we need to do it quickly, since, as Hippocrates wrote, “The art is long but life is short.”

Disclosure: Brilakis reports receiving consultant/speaker honoraria from Abbott Vascular, Asahi, Cardinal Health, Elsevier, GE Healthcare and St. Jude Medical; research support from Boston Scientific and InfraRedx; and his spouse is an employee of Medtronic.