As an interventional cardiology fellow, you’ll have the opportunity to participate in procedures of varying complexity. After a few hundred cases, you’ll feel ready to be an independent coronary operator. At this point in your career, with seven or more years of training behind you, it’s likely that you’ll want to settle down into full-time practice with a salary that can support your family. Although you may be interested in complex coronary artery disease, you may figure you can learn some of the advanced PCI techniques on the job.

So why commit to one more year of training? The opportunity to perform a large volume of cases of complex higher-risk indicated patients (CHIP) and chronic total occlusion (CTO) patients under the supervision of an outstanding mentor is the main reason to extend your training another year.

In routine clinical practice, it’ll be challenging to achieve the same case load with proctors, while also struggling to establish yourself in your new job. On the other hand, participating in a CHIP/CTO fellowship will allow you to quickly become familiar with the novel equipment and advanced PCI techniques necessary for CTO intervention. This includes mastering the ability to wire retrograde collaterals and perform reverse controlled antegrade reentry and retrograde subintimal tracking (CART), as well as gaining comfort with the hybrid algorithm developed by Emmanouil S. Brilakis, MD, PhD, FACC.

What is less obvious – yet highly beneficial – is the improvement in your non-CTO operator skills.

What is less obvious – yet highly beneficial – is the improvement in your non-CTO operator skills. After performing over 500 PCIs during my interventional fellowship with only a little exposure to CTO PCI, the CTO training program was officially started at the Beth Israel Deaconess Medical Center (bidmc.org/ctocare) by Robert W. Yeh, MD, FACC.

Following this, my CTO case volume significantly increased. I began developing a skill set that’s difficult to describe. As Aaron Grantham, MD, (self-proclaimed CTO geek at St. Luke’s Mid America Heart Institute) says, you “feel with your eyes,” and manipulate wires differently and choose different equipment, even for routine cases, because of the experience with CTO cases. You also evaluate patients differently, learn how to decrease your radiation exposure and contrast usage, and change your overall approach to your coronary cases.

One of the more satisfying results of this extra training was when I was called on by one of my more senior interventional colleagues to assist with a balloon-uncrossable lesion. Quickly, I found myself able to efficiently spin a micro-catheter, cross the lesion, and solve the case (which included swapping the wire, performing rotational atherectomy and deploying a stent).

Similarly, I remember the personal gratification of being able to help a colleague when he had a guide dissection in a sick patient. I was able to solve the case by “STARing” (i.e., pushing a small knuckled wire subintimally) to quickly restore flow to the distal vessel. By undergoing this extra PCI training, you’ll be able to easily distinguish luminal and subintimal wire position or use of reentry strategies, as well as deal with a perforation that needs embolization/coiling.

There are only a limited number of programs in the country with a high volume of CTO PCIs to support a fellowship. Irrespective of the high CTO PCI success rate at these programs, one will eventually fail to cross a lesion during a procedure. It’s during these cases where the extra learning occurs, as you’ll have the opportunity to review technical options with the best CTO operators nationwide. You’ll critically analyze your failures and develop a more profound perspective to devise a better plan for the second attempt.

Reviewing other operators’ failures that are referred to you will provide you with challenging cases. Sometimes you’ll solve these cases using a simple CTO technique. At other times, they’ll be extremely challenging and force you to take your skills to the next level.

Starting a CTO program requires an additional set of skills that are developed during a CHIP fellowship. You need to learn how to educate referring physicians, co-fellows and interventional cardiologists about CTO PCI options; discuss the benefits and risks of the procedure; and develop a method for building a good referral base.

Surprisingly, some physicians do not consider revascularization options for CTOs in symptomatic patients, even when there’s evidence of ischemia. Contrarily, referring physicians may send asymptomatic patients who cannot benefit from CTO PCI. Thus, evaluating patients in clinic is quite useful in learning how to determine the appropriateness for CTO PCI, which is integral for building a good CTO program.

Taking care of patients with very complex diseases who are tenuous and sick is gratifying. Yet, high-risk procedures also have a higher mortality rate. You’ll eventually have to cope with a patient’s death. This is a topic no one talks about. The support of CHIP/CTO operators who understand how hard this can be is invaluable. You’ll never be fully prepared and it’ll always be difficult, but this is part of taking care of these complex patients.

Finally, as part of some fellowships, you may have the opportunity to have routine cath lab days and enter into the STEMI call rotation. This will allow you to perform your first cases with a “safety net” of your mentors and colleagues, which may not be present otherwise in routine clinical practice. This provides a nice transition towards becoming an independent operator and will help build confidence for when you perform your first PCI entirely by yourself.

A CHIP/CTO fellowship will provide you with the skills to become a better interventionalist – and make you a better clinician overall. If you have an interest in complex coronary cases, I urge to you strongly consider following the path I’ve chosen.

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This article was authored by Hector Tamez, MD, MPH, a CHIP/CTO fellow at Beth Israel Deaconess Medical Center. His clinical and research interests lie in CHIP/CTO and their outcomes, specifically in hemodynamic support, antithrombotic/antiplatelet therapies and their interaction and heterogeneous effects in the population in regard to bleeding and thrombosis. After finishing his fellowship, Tamez plans to pursue a career in academic interventional cardiology and to continue the care of CHIP/CTO patients and focus on cardiovascular outcomes research.

Keywords: ACC Publications, Cardiology Interventions, Atherectomy, Coronary, Myocardial Infarction, Coronary Artery Disease, Fellowships and Scholarships, Mentors, Learning, Stents, Mental Recall, Salaries and Fringe Benefits, Referral and Consultation, Algorithms, Risk Assessment

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