Dilemmas in cardiology: when to recanalize a chronic total occlusion

The decision whether or not to recanalize a chronic total occlusion (CTO) of a coronary artery is truly a dilemma for the cardiologist. The procedure is in fact complex, with a non-negligible rate of complications and with a probability of success lower than that of non-obstructive lesions. The analysis of the data available in the literature, with the significant discrepancy between the results of the randomized studies and the observational studies, does not currently allow conclusive statements on the role of the percutaneous coronary interventions in CTO. It is therefore essential to incorporate clinical, anatomical and procedural elements into the decision-making algorithm. While awaiting new randomized clinical trials of greater dimensions and better methodology, a careful selection of patients is certainly essential, limiting the procedure to those who are symptomatic or who have a high ischaemic burden and excluding those who have no evidence of vitality, without which it is not legitimate to expect any benefit from the intervention. Finally, the presence of the collateral circulation does not in itself appear to be an element that should have a significant decision-making role.