Taming Ostial LAD Ambiguous Cap CTO

Chronic total occlusion (CTO) percutaneous coronary interventions have more complications due to intrinsic complexity of procedure which is further compounded by ambiguity of proximal cap. If the ambiguous proximal cap CTO is at ostial left anterior descending artery (LAD), impact of complications is huge as the area of myocardium at risk is significant. Hence, while treating ambiguous proximal cap CTO at ostial LAD or left circumflex artery (LCX), special attention must be given to prevent or minimize inflow injuries like dissection or intramural hematoma (IMH) of left main coronary artery (LMCA) and its branches. In order to prevent such complications, all the available CTO techniques need to be understood in this context and executed to keep procedural outcomes as predictable as possible. Intravascular ultrasound (IVUS) imaging is the passkey in wiring and detecting inflow injury to prevent intraprocedural catastrophes. This article explores the refinement and modification of existing techniques of CTO PCI and the use of imaging in the context of ostial LAD CTO PCI.