Scoring systems for chronic total occlusion percutaneous coronary intervention: if you fail to prepare you are preparing to fail

Scoring systems for chronic total occlusion percutaneous coronary intervention: if you fail to prepare you are preparing to fail

Aris Karatasakis, Barbara Anna Danek, Emmanouil S. Brilakis

VA North Texas Healthcare System and University of Texas Southwestern Medical Center, Dallas, TX, USA

Correspondence to: Emmanouil S. Brilakis, MD, PhD. Dallas VA Medical Center (111A), 4500 South Lancaster Road, Dallas, TX 75216, USA. Email:

Submitted Jun 21, 2016. Accepted for publication Jun 29, 2016.

doi: 10.21037/jtd.2016.08.20

While the benefit of chronic total occlusion (CTO) percutaneous coronary intervention (PCI) has not yet been demonstrated in randomized controlled trials, several observational studies have shown that, as compared with failed procedures, successful CTO PCI is associated with significant clinical benefit (1). It is, therefore, imperative to maximize the likelihood of CTO PCI success. Accordingly, the American College of Cardiology Foundation/American Heart Association/Society for Cardiovascular Angiography and Interventions PCI guidelines, have assigned a class IIa recommendation for CTO PCI to be performed in patients with suitable anatomy by operators with sufficient expertise (2). A key contributor to achieving success in CTO PCI is meticulous preparation; to aid with planning, operators and centers from around the world have created CTO PCI prediction scores (Table 1) (3-11).

Table 1
Table 1 Currently available scoring systems for CTO PCI
Full table

Scoring systems can be useful in several ways. First, they provide a quantitative measure of the likelihood of success and complications that can be shared with the patient and help with clinical decision-making. Second, by providing the means for more objective assessment of anatomic and clinical complexity, CTO scores enable better case selection: while seasoned operators can tackle even the toughest of cases with high success rates (12), operators early in the CTO PCI learning curve can select “simpler” cases, referring the more unfavorable cases to specialized centers, or performing them with the guidance of a proctor. Within the heart team, the decision to revascularize and the optimal strategy can be tailored to each patient, taking into account the objective probability of achieving technical/angiographic success with PCI. Third, CTO scores provide a valuable template for guiding review of the coronary angiogram. At least 15 minutes of careful review and evaluation are essential to understand the lesion and develop a “plan of attack” (primary retrograde vs. antegrade approach, intimal or sub-intimal and wire or crossing device based strategies) (13,14). Fourth, standardized classification of CTO lesion complexity allows comparison of outcomes with different approaches, between operators, centers, countries and even continents, for both quality improvement and clinical research.

The first CTO scoring system was the J-CTO (multicenter CTO registry in Japan) score, created by Morino et al. to predict successful guidewire crossing within 30 minutes (3). The J-CTO score is currently the most widely used score, and its inception sparked a series of scoring systems created to predict not only successful wiring and procedural efficiency, but also technical success, contrast induced nephropathy and even complications. Newer scores use various clinical, imaging and laboratory parameters. But is the creation of more than one score necessary and useful? The answer is definitely yes, and here is why:

First, development of new scoring systems helps validate previously published scores. For example, in the J-CTO score proximal cap morphology, coronary calcification and tortuosity are variables affecting the outcome of CTO PCI; as shown in the Table, these variables are included in most other scores, reinforcing their importance. The ability of the J-CTO score to predict quick guidewire crossing (15), the need for advanced crossing techniques (8,12), as well as mid- and long-term outcomes (16,17) has been confirmed in multiple studies; however, its ability to predict technical success was not consistent in all studies (6,8,15).

Despite similarities, newer scores often include different variables previously unexplored or found to not be predictive of outcome, highlighting the variety in approaches to CTO PCI. For example, the ORA (ostial location, Rentrop grade <2, age ≥75 years) score by Galassi et al. reflects the creator’s extensive experience with retrograde techniques and may thus be more suitable for hybrid or retrograde operators (6). The clinical and lesion-related (CL) score by Alessandrino et al. was created based on primarily antegrade procedures and may thus perform better for antegrade-only operators (4). The PROGRESS CTO (Prospective Global Registry for the Study of Chronic Total Occlusion Intervention) score variables align with the hybrid algorithm for CTO PCI (5). In centers with high computed tomography angiography utilization, CT-based scores such as the CT-RECTOR (Computed Tomography Registry of Chronic Total Occlusion Revascularization) score may be of great value (10).

One disadvantage of scoring systems lies within the misconception that a high score (usually corresponding to complex coronary anatomy) is synonymous with failure. This is unfounded, since expert centers from around the world have reported very high success rates even with very complex CTOs (12).

In conclusion, CTO PCI scoring systems can be a tremendous resource for both the novice and experienced CTO operator, to aid with case and approach selection as well as to predict procedural efficiency and the probability for success and even complications. The creation of new scores to suit different CTO practices, and the validation of already existing scoring systems should be encouraged.




Conflicts of Interest: ES Brilakisconsulting/speaker honoraria from Abbott Vascular, Asahi, Boston Scientific, Elsevier, Somahlution, St Jude Medical, and Terumo; research support from Boston Scientific and InfraRedx; spouse is employee of Medtronic. A Karatasakis and BA Danek have no conflicts of interest to declare.

Response to: Boukhris M, Mashayekhi K, Elhadj ZI, et al. Predictive scores in chronic total occlusions percutaneous recanalization: only fashionable or really useful? J Thorac Dis 2016;8:1037-41.


  1. Christakopoulos GE, Christopoulos G, Carlino M, et al. Meta-analysis of clinical outcomes of patients who underwent percutaneous coronary interventions for chronic total occlusions. Am J Cardiol 2015;115:1367-75. [Crossref] [PubMed]
  2. Levine GN, Bates ER, Blankenship JC, et al. 2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Society for Cardiovascular Angiography and Interventions. Circulation 2011;124:e574-651. [Crossref] [PubMed]
  3. Morino Y, Abe M, Morimoto T, et al. Predicting successful guidewire crossing through chronic total occlusion of native coronary lesions within 30 minutes: the J-CTO (Multicenter CTO Registry in Japan) score as a difficulty grading and time assessment tool. JACC Cardiovasc Interv 2011;4:213-21. [Crossref] [PubMed]
  4. Alessandrino G, Chevalier B, Lefèvre T, et al. A Clinical and Angiographic Scoring System to Predict the Probability of Successful First-Attempt Percutaneous Coronary Intervention in Patients With Total Chronic Coronary Occlusion. JACC Cardiovasc Interv 2015;8:1540-8. [Crossref] [PubMed]
  5. Christopoulos G, Kandzari DE, Yeh RW, et al. Development and Validation of a Novel Scoring System for Predicting Technical Success of Chronic Total Occlusion Percutaneous Coronary Interventions: The PROGRESS CTO (Prospective Global Registry for the Study of Chronic Total Occlusion Intervention) Score. JACC Cardiovasc Interv 2016;9:1-9. [Crossref] [PubMed]
  6. Galassi AR, Boukhris M, Azzarelli S, et al. Percutaneous Coronary Revascularization for Chronic Total Occlusions: A Novel Predictive Score of Technical Failure Using Advanced Technologies. JACC Cardiovasc Interv 2016;9:911-22. [Crossref] [PubMed]
  7. Chai WL, Agyekum F, Zhang B, et al. Clinical Prediction Score for Successful Retrograde Procedure in Chronic Total Occlusion Percutaneous Coronary Intervention. Cardiology 2016;134:331-9. [Crossref] [PubMed]
  8. Wilson WM, Walsh SJ, Yan AT, et al. Hybrid approach improves success of chronic total occlusion angioplasty. Heart 2016;102:1486-93. [Crossref] [PubMed]
  9. Liu Y, Liu YH, Chen JY, et al. A simple pre-procedural risk score for contrast-induced nephropathy among patients with chronic total occlusion undergoing percutaneous coronary intervention. Int J Cardiol 2015;180:69-71. [Crossref] [PubMed]
  10. Opolski MP, Achenbach S, Schuhbäck A, et al. Coronary computed tomographic prediction rule for time-efficient guidewire crossing through chronic total occlusion: insights from the CT-RECTOR multicenter registry (Computed Tomography Registry of Chronic Total Occlusion Revascularization). JACC Cardiovasc Interv 2015;8:257-67. [Crossref] [PubMed]
  11. Ito T, Tsuchikane E, Nasu K, et al. Impact of lesion morphology on angiographic and clinical outcomes in patients with chronic total occlusion after recanalization with drug-eluting stents: a multislice computed tomography study. Eur Radiol 2015;25:3084-92. [Crossref] [PubMed]
  12. Christopoulos G, Wyman RM, Alaswad K, et al. Clinical Utility of the Japan-Chronic Total Occlusion Score in Coronary Chronic Total Occlusion Interventions: Results from a Multicenter Registry. Circ Cardiovasc Interv 2015;8:e002171. [Crossref] [PubMed]
  13. Brilakis ES. Manual of Coronary Chronic Total Occlusion Interventions: A Step-by-Step Approach. 1 edition. Academic Press, 2013.
  14. Brilakis ES, Grantham JA, Rinfret S, et al. A percutaneous treatment algorithm for crossing coronary chronic total occlusions. JACC Cardiovasc Interv 2012;5:367-79. [Crossref] [PubMed]
  15. Nombela-Franco L, Urena M, Jerez-Valero M, et al. Validation of the J-chronic total occlusion score for chronic total occlusion percutaneous coronary intervention in an independent contemporary cohort. Circ Cardiovasc Interv 2013;6:635-43. [Crossref] [PubMed]
  16. Tanaka H, Morino Y, Abe M, et al. Impact of J-CTO score on procedural outcome and target lesion revascularisation after percutaneous coronary intervention for chronic total occlusion: a substudy of the J-CTO Registry (Multicentre CTO Registry in Japan). EuroIntervention 2016;11:981-8. [Crossref] [PubMed]
  17. Galassi AR, Sianos G, Werner GS, et al. Retrograde Recanalization of Chronic Total Occlusions in Europe: Procedural, In-Hospital, and Long-Term Outcomes From the Multicenter ERCTO Registry. J Am Coll Cardiol 2015;65:2388-400. [Crossref] [PubMed]
Cite this article as: Karatasakis A, Danek BA, Brilakis ES. Scoring systems for chronic total occlusion percutaneous coronary intervention: if you fail to prepare you are preparing to fail. J Thorac Dis 2016;8(9):E1096-E1099. doi: 10.21037/jtd.2016.08.20