Navigating The Complexity Of CTO Interventions: Why Tertiary Cardiac Centres Must Invest In Advanced PCI Capabilities

Much of the attention in cardiac care across India is directed at emergencies, such as heart attacks or advanced stages of heart failure. Still, there’s a group of cardiac patients that tends to be overlooked those living with long-standing total blockages. These arteries have stayed shut for months. The symptoms aren’t always obvious right away, but over time, the strain on the heart adds up. Many individuals in this group live with persistent chest discomfort and a gradual decline in heart function, which can take a serious toll on their day-to-day life if not treated at the right time.

India sees a high burden of coronary artery disease, and CTOs are not uncommon. Data suggests that approximately 15–20 per cent of patients undergoing coronary angiography are diagnosed with at least one CTO. Despite this prevalence, most of these patients are managed conservatively not because intervention isn’t viable, but due to limited access to centres with the expertise, infrastructure, and confidence to perform advanced CTO PCI (percutaneous coronary intervention). Addressing this gap requires deliberate investment by tertiary cardiac centres.

Why CTO PCI Matters

CTO PCI, when done successfully, restores perfusion to ischemic myocardial territories, often resulting in improved left ventricular function, reduced angina, and enhanced exercise tolerance. Multiple international studies support the long-term benefits of complete revascularisation in these patients, showing reduced hospitalisation and improved survival in selected cohorts. Importantly, this procedure offers a therapeutic lifeline for patients who have been told their condition is inoperable or unmanageable.

Yet, CTO PCI is not a routine intervention. It requires not just advanced hardware but also a high level of operator expertise and multidisciplinary support. Centres must develop robust clinical frameworks to ensure both safety and efficacy.

What Tertiary Centres Must Prioritise

1. High-Volume, Skilled Operators

The success rate of CTO PCI is strongly influenced by the cardiologist’s level of experience. Those who handle a higher volume of these procedures—typically 15 or more each year—tend to be more adept at navigating difficult anatomical situations, making real-time adjustments, and managing potential complications effectively. Ongoing training and a supportive learning environment play a key role in refining these skills and maintaining consistently safe outcomes.

1. Access to Advanced Tools

Treating a chronic total occlusion isn’t straightforward. It can’t be done with just the regular PCI setup. Often, the procedure needs additional tools—microcatheters, special guidewires, imaging from inside the vessel, and systems that let the operator switch techniques if needed. These tools are essential, not optional, for centres aiming to offer comprehensive CTO care.

1. Team-Based Protocols and Clinical Pathways

A successful CTO program hinges on seamless teamwork. Procedural duration is often longer than standard PCI, requiring synchronised efforts across cardiologists, cath lab staff, anesthetists, and post-procedure care units. Protocols should be algorithm-driven, reducing procedural fatigue and enabling standardised care.

1. Emergency and Safety Infrastructure

Although complication rates are low in experienced hands, CTO PCI carries inherent risks—coronary perforation, contrast-induced nephropathy, and arrhythmias. A tertiary centre must be equipped with surgical backup, rapid-response teams, and post-PCI monitoring capabilities to handle emergencies effectively.

1. Ongoing Follow-Up Matters

The outcomes of CTO revascularisation often take time to fully show, unlike standard PCI procedures. Patients need regular monitoring to track symptom relief, fine-tune their medications, and maintain adherence to lifestyle changes. Incorporating imaging and periodic clinical reviews into their care helps ensure the benefits of the procedure are sustained in the long run.

The Role of AI: A Missed Opportunity in Most CTO Programs

While advances in tools and operator expertise have improved CTO PCI success rates, one area that remains underutilised is artificial intelligence. AI-driven technologies—ranging from predictive algorithms to imaging interpretation—are beginning to demonstrate real value in complex coronary interventions globally.

When planning treatment for chronic total occlusions, artificial intelligence is increasingly being explored for its potential to support clinical decisions. It can be used to analyse CT angiograms, provide insights into the likely complexity of the blockage, and assist in selecting the most appropriate route for intervention. Some newer technologies include physiological modelling tools like FFR-CT, which are useful when decisions need to be made in borderline or complex cases. Yet, in many tertiary care centres across India, AI adoption is still lagging. The roadblocks are familiar: high investment costs, limited clinical training, and a lack of streamlined digital systems that support everyday clinical use.

As data sets expand and algorithm accuracy improves, incorporating AI could significantly streamline procedural planning, reduce operating time, and enhance safety, especially in high-volume centres looking to scale CTO services responsibly.

The Strategic Case for Investment

Today’s patients are well-informed and willing to seek second opinions. Many who are labelled "inoperable" due to complex anatomy are actively searching for centres that offer newer, evidence-backed options. Tertiary hospitals that establish structured CTO programs can position themselves as centres of excellence, thereby attracting referrals and improving case-mix complexity.

Insurance coverage in India has gradually expanded. Today, both private providers and public health schemes are beginning to include complex coronary procedures like CTO PCI. As these policies become more established, more patients can access advanced cardiac treatments without facing overwhelming financial pressure.

From a system-wide perspective, strengthening interventional cardiology capabilities—especially for CTOs—is both a medical responsibility and a forward-thinking strategy. It supports national efforts to manage non-communicable diseases, enhances tertiary-level referral systems, and creates new opportunities for training and clinical innovation.

Chronic total occlusions are no longer confined to the margins of cardiovascular care. When cardiology teams are backed by proper training, clear protocols, and reliable tools, CTO PCI has the potential to improve outcomes for patients who once had very few treatment avenues. For India’s tertiary heart centres, the message is clear: building this expertise now is essential to meet the clinical challenges ahead. It’s a step that expands both clinical capacity and the hospital’s ability to offer focused, results-oriented cardiac care.

Reference Link

https://www.bwhealthcareworld.com/article/navigating-the-complexity-of-cto-interventions-why-tertiary-cardiac-centres-must-invest-in-advanced-pci-capabilities-568481