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Page 10 of 11 Zivelonghi et al. Vessel Plus 2019;3:30 I http://dx.doi.org/10.20517/2574-1209.2019.06

CONCLUSION
The application of the hybrid strategies allows to achieve extremely highly procedural success rates with
limited complication incidence. Although AWE is often used as an initial technique, this approach alone
has a low success rate in the most complex CTO lesions. As suggested in the hybrid algorithm, when the
characteristics of the CTO-lesion appear not favorable (especially when the lesion length is more than
20 mm) the direct use of a dissection re-entry technique can be considered -both antegrade or retrograde-
depending on the proximal cap characteristics and the distal vessel morphology. Implementing this
strategy could result in higher success rate, lower complication rate and a limitation of the radiation
exposure for both operators and patients, as well as contrast exposure for the patients. Another important
consideration is that the operators should be trained for the management of potentially life-threatening
complications, like coronary perforation and cardiac tamponade.

FUTURE DIRECTIONS
The hybrid approach has been proven to be very effective and has also shown to reduce the rate of
complications. The next step is to train potential CTO operators so that the correct diffusion of this
algorithm will further improve success rates, especially in lower CTO PCI volume centers. In our view
proctoring is a crucial step for a steep increase in expertise of new CTO operators. Moreover, we need
efforts to further improve patient comfort and to reduce access related complications by minimizing the
use of dual access, large bore catheters and femoral approach when it is possible, without impacting the
efficiency of the hybrid algorithm.

DECLARATIONS
Authors’ contributions
Made substantial contributions to conception and design of the study and performed data analysis and
interpretation: Zivelonghi C, Budassi S, Agostoni P
Performed data acquisition, as well as provided administrative, technical, and material support: Budassi S,
Zivelonghi C, Agostoni P

Availability of data and materials
Not applicable.

Financial support and sponsorship
None.

Conflicts of interest
All authors declared that there are no conflicts of interest.

Ethical approval and consent to participate
Not applicable.

Consent for publication
Not applicable.

Copyright
© The Author(s) 2019.