The following are key points to remember from this study about the hybrid approach to chronic total occlusion (CTO) percutaneous coronary intervention (PCI):

1. CTO PCI has been evolving, with constant improvement of equipment and techniques.
2. The hybrid approach to CTO PCI advocates dual coronary injection, careful and structured review of the angiogram, and flexibility with use of all crossing strategies (i.e., antegrade wire escalation, antegrade dissection reentry, and the retrograde approach encouraged).
3. The largest experience with hybrid CTO PCI performed to date, with over 3,000 patients performed at 20 centers between 2012-2017, reported a technical success of 87% and the risk for in-hospital major complications of 3%, providing important benchmarks to use when discussing with patients and providers the risk/benefit ratio of CTO PCI.
4. Antegrade wire escalation was more commonly applied as the initial crossing approach (74%) in less complex lesions (J-CTO score 2.24 ± 1.24, PROGRESS CTO score 1.32 ± 0.87), and was the most common final crossing strategy (in approximately half of the cases).
5. Antegrade dissection reentry and retrograde techniques were more likely to be used as initial strategy in cases with complex anatomy (J-CTO score 2.78 ± 1.21 and 3.32 ± 0.98, respectively; PROGRESS CTO score 1.38 ± 0.93 and 2.00 ± 0.89, respectively), and were the final successful strategy in 22% and 28% of all cases.
6. Failure to cross with a guidewire was the most common reason for CTO PCI failure (in 86%).
7. It should be noted that despite the encouraging findings from this study and other contemporary registries, the success rates of CTO interventions in unselected patient cohorts remain low.
8. Furthermore, procedural complications are more frequent after CTO PCI compared with non-CTO PCI, and along with contrast nephropathy, bleeding, radiation exposure, and costs must be taken into account when considering the risk/benefit balance of complex CTO procedures.
9. Overall, it appears that CTO PCI is currently being performed with high success and acceptable complication rates among various experienced centers in the United States and Europe, and is an effective revascularization strategy in appropriately selected patients.
10. There is a need for developing more CTO PCI centers of excellence in order to achieve the best possible clinical outcomes in this challenging patient and lesion group. Such centers should report rigorously collected outcome data including hard clinical endpoints.

Keywords: Angiography, Coronary Occlusion, Diagnostic Imaging, Hemorrhage, Myocardial Ischemia, Myocardial Revascularization, Outcome Assessment, Health Care, Percutaneous Coronary Intervention, Radiation, Registries, Risk, Secondary Prevention

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