Abstract
Chronic total occlusions (CTOs) represent one of the most technically demanding areas of percutaneous coronary intervention (PCI). Despite advances in equipment and operator expertise, CTO PCI remains associated with lower procedural success rates and a higher risk of complications than non-CTO PCI. This review summarizes emerging techniques and technologies designed to improve procedural efficiency, safety, and outcomes in contemporary, personalized patient care. Recent innovations span multiple domains of CTO PCI. The minimalistic hybrid approach (MHA) aims to reduce vascular complications by minimizing the number of access sites and the sheath size. Novel perforation management strategies, including the cut balloon technique (CBT) and the condom technique, offer simple, low-cost options for distal vessel sealing, supported so far only by small series and technical reports. Advanced re-entry methods, such as tip-detection, antegrade dissection and re-entry (TD-ADR), integrate intravascular ultrasound (IVUS) to enhance precision. HydroDynamic contrast recanalization (HDR) revisits hydraulic dissection with a controlled, microcatheter-based contrast strategy whose safety profile remains to be established. The microcatheter anchor technique (MAT) has been proposed to facilitate retrograde CTO PCI in post-CABG anatomy. New plaque-modifying strategies, including RODIN-CUT and ORCAS, leverage high-pressure cutting balloon inflations under real-time IVUS guidance. Additional technologies, such as Plasmawire™, Shockwave Javelin®, and Hertz Contact intravascular lithotripsy (IVL), may expand the armamentarium for crossing and modifying complex CTO lesions, although CTO-specific clinical data are very limited (for Javelin, a 20-patient first-in-human coronary series). CT coronary angiography (CTCA) continues to improve pre-procedural planning, while drug-coated balloons (DCBs) show promise in selected de novo CTO lesions, although the evidence remains limited to retrospective series. Taken together, this rapid pace of innovation is steadily widening the procedural toolkit available for CTO PCI and may improve outcomes. Evidence for most of these techniques comes from case reports, small single-center series, and early-phase single-arm studies. It suggests feasibility in selected patients, but safety data are limited, and some reports signal concerns, including tamponade after the cut balloon technique and a higher perforation rate in a registry of the Carlino technique. The place of these techniques in routine practice will become clear only once larger, multicenter trials are completed.