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The use of subintimal pathways to facilitate chronic total occlusion procedural success

JW Strange

The use of the subintimal space to facilitate chronic total occlusion (CTO) angioplasty has, over the years, caused a degree of controversy. Some experts recommend avoiding the subintmal space at all cost, whereas others place it squarely within an algorithm to help achieve an efficient, effective and safe CTO program. There is no doubt that the use of the subintimal space has improved CTO procedural success, defined as luminal continuity and thrombolysis in myocardial infarction grade III flow, with more operators reporting 95% success rates in unselected cases. However, the preferred techniques used to achieve this have evolved, with some becoming historical or a last resort. The debate over the role of the subintimal space and its long-term safety still continues. This article will aim to give insight into the anatomy, techniques and outcomes in subintimal CTO intervention.