CTO revascularization: Obstacles and options in balloon nonpenetrable lesions

Key Points

• CTO lesions resisting balloon crossing are located in moderate/severe tortuous coronary arteries contain more moderate/severe calcification burden and carry a higher J-CTO score as compared with balloon crossable CTO lesions.
• CTO lesions resisting balloon crossing do not constitute a homogenous group. In 25% of the patients, the resisting CTO was caused by stent restenosis and thrombus is an integral component of CTO in addition to calcium and fibrosis.
• The excimer laser and rotational/orbital atherectomy are among useful debulking technologies capable of creating a "pilot recanalization channel" in the CTO that enables completion of the revasularization.

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