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The history of percutaneous recanalisation of chronic total coronary occlusions (CTO) reaches back to the mid 1980s when, little by little, stiffer wires appeared on the market. Most of the reports of CTO results in those days included “well selected cases” and used a more liberal definition including recent occlusions, so that the reported success rates of >60% are not realistic with respect to the types of lesions treated today1. The steep improvement of success rates by dedicated CTO operators, now reaching 90% in Japan and also in Europe and other parts of the world, was made possible by the introduction of new techniques in the past ten years, spearheaded by pioneers like O. Katoh, H. Tamai and T. Suzuki, combined with educational efforts by groups like the Japanese, and the European CTO club2-4. The most important milestones on the road to success were the development of dedicated wires with different physical characteristics (a development that is still ongoing), the availability of microcatheters, and of course the introduction of drug-eluting stents which made it possible to preserve the initial interventional success over time. The ultimate advance in success rates was achieved by the introduction of the retrograde technique, using the tiny collateral connections between donor artery and occluded vessels5. The retrograde approach rapidly gained wide appreciation and is applied by some operators in up to 30-50% of their CTO procedures, although it may require more time, material, dye and radiation than the antegrade approach, as depicted by the results of the Euro CTO club registry6. One of the inherent problems of passing a wire through a CTO is the deviation into the subintimal space, and then the redirection into the true lumen. This can be achieved by using additional wire(s) in parallel, by attempting a re-entry with either stiff or alternatively soft polymeric wires. The latter is an attempt to salvage otherwise failed procedures by an uncontrolled re-entry, called STAR (subintimal tracking and re-entry) with very poor long-term outcome due to the extensive dissections7,8. However, even controlled antegrade techniques and especially the retrograde approach using the CART (controlled antegrade and retrograde subintimal tracking) manoeuvre to connect the wire positions of the antegrade and retrograde wire involve conceptually a subintimal pathway of the wire(s)9. The J-PROCTOR registry is one of the first studies to evaluate systematically the incidence of the subintimal wire pathway by using intravascular ultrasound (IVUS) before stent placement for the contemporary CTO recanalisation technique10. IVUS is certainly the best available method to verify coronary wall structure and the location of the wire pathway in these often complex and long lesions9.

Subintimal wire pathway: part of the game of crossing chronic total coronary occlusions