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CTO revascularization: Obstacles and options in balloon nonpenetrable lesions

CTO lesions resisting balloon crossing are located in moderate/severe tortuous coronary arteries contain more moderate/severe calcification burden and carry a higher J‐CTO score as compared with balloon crossable CTO lesions. CTO lesions resisting balloon crossing do not constitute a homogenous group. In 25% of the patients, the resisting CTO was caused by stent restenosis and thrombus is an integral component of CTO in addition to calcium and fibrosis. The excimer laser and rotational/orbital atherectomy are among useful debulking technologies capable of creating a “pilot recanalization channel” in the CTO that enables completion of the revasularization.