Chronic total occlusion (CTO) remains the final frontier of coronary interventions. There is a multitude of benefits to be gained from the CTO recanalization in a symptomatic patient or someone with CTO-attributed ischemia. These include but are not limited to relief of angina, reduction of ischemic burden, improved quality of life, improvement of left ventricular function, better tolerance for future ischemic events, especially in the situation of STEMI in the non-CTO territory, reduced risk of ventricular arrhythmias, fewer antianginal medications, and mortality benefit.
Traditionally, CTO PCI has been performed via the femoral approach, allowing for larger-bore 7 Fr and 8 Fr catheters that confer better passive support and non-restricted equipment utilization. After working in a transradial center and knowing the benefits of radial vs. femoral access for several years, along with improved patient quality of life after the former, we developed a successful CTO program since 2009, primarily using the transradial approach. Presently, the transradial approach represents a promising alternative to transfemoral approach in patients undergoing CTO PCI in many high-volume transradial centers. In this chapter, we share our knowledge, experience, tips and tricks, and limitations with transradial CTO PCI and review basic principles and techniques practiced by the hybrid CTO PCI school. The readers will notice that there are very few limitations for CTO PCI to be performed via transradial approach.