Clinical Snapshot
PICO Framework
| P — Population | Patients with chronic total occlusion (CTO) of coronary arteries undergoing percutaneous coronary intervention |
| I — Intervention | Supplementary intravascular ultrasound and advanced maneuvers for proximal cap assessment |
| C — Comparator | Standard angiographic assessment alone |
| O — Outcomes | Safety and efficiency of percutaneous coronary intervention, successful proximal cap crossing |
Bottom Line
This narrative review addresses the technical challenge of proximal cap ambiguity in chronic total occlusion percutaneous coronary intervention, recommending supplementary intravascular ultrasound and advanced maneuvers to improve procedural safety and efficiency. While the topic is clinically relevant and the recommendations appear reasonable, the review lacks systematic methodology and provides no quantitative evidence for the effectiveness of suggested approaches. The guidance may be valuable for experienced interventional cardiologists but should be considered expert opinion rather than evidence-based recommendations. Clinicians should seek additional evidence from randomized trials and systematic reviews when available, and ensure appropriate training and institutional support before implementing advanced CTO techniques.
Key Findings
Effect Size: Not quantified
Primary Outcome: Technical approaches to resolve proximal cap ambiguity in CTO PCI
Nnt Or Sensitivity: Success rates for recommended techniques not specified
Confidence Interval: Not provided
Clinical Application
Requires advanced interventional skills and specialized equipment including IVUS capability Relevant to Australian interventional cardiology practice; IVUS available through PBS for specific indications; techniques applicable in tertiary cardiac centres with CTO expertise Interventional cardiologists performing CTO PCI procedures
Abstract
This article reviews how to approach the proximal cap of a chronically occluded coronary artery. Safely crossing this region of the lesion is a crucial step in the procedure. While many proximal caps are understood angiographically, a significant proportion are not. This article describes steps that can be taken to resolve anatomic ambiguity, either by the use of supplementary intravascular ultrasound or by more advanced maneuvers, which should enhance the safety and efficiency of the percutaneous coronary intervention.
References
- 1.Walsh, S. J. (2026). Proximal cap ambiguity. Interventional Cardiology Clinics, 15(1). https://doi.org/10.1016/j.iccl.2025.09.015
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