James C Spratt  英国爱丁堡诊所
　　James C Spratt英国爱丁堡诊所心脏病专家顾问，斯特林皇家医院和爱丁堡皇家医院医生，第四峡谷经营普通心脏病诊所。其致力于介入心脏病学、心脏CT、高血压和心肌疾病的研究。
　　因心源性胸痛行冠状动脉造影的患者中冠状动脉慢性完全闭塞（CTO）占18%～30%，且CTO是血管重建失败的预测因子。冠状动脉旁路移植术（CABG）中隐静脉移植（SVG）至CTO后，血管的1年开放率＜40%。
　　CTO患者行经皮冠状动脉介入术（PCI）成功率较低（在高选择病例中占60%），因此倾向于药物治疗或行CABG。尽管少数专家的技术进步显著（未经选择病例成功率＞95%），但大多数医生认为无法掌握此技术，原因之一为技术和设备持续更新和细化，而现在根本的障碍是缺乏结构化的培训计划。
　　成功的培训计划应是可教的，可再生的，而且有各种教育方法。支撑CTO平台的三个基本技能为平行导引钢丝技术、解剖重返技术和逆行技术。这些技术互补，由患者病变解剖特征和预定或程序因素决定其使用方式，技术的关键是对程序有效。行CTO手术医生的良好的冠状动脉介入技术基础非常重要，额外的技能与传统PCI不同。基于概念的基本原理和技术描述要清晰。这是多方面教育平台最好的做法。
　　CTO教育平台的基础是有现场案例展示的大型会议，介绍可行的技术，但不专注于技术细节。会议的目标人群为更懂CTO PCI的少数人，但会议也常关注现场案例，因此教学是不可预知的和案例依赖性的。我们对关于CTO基本原理开展为期一天的一系列讲习班，以解决大家对于结构良好的学习的需要，其基于多个记录的现实案例，并允许医生讲述临床中棘手问题。教育的最后部分是面对面监督，CTO外科专家访问心脏实验室和监督当地医生，帮助其引进新技术，必要时帮助行介入治疗。这些需要已备好易得的参考材料的支持。在www.ctofundamentals.org网站，医生可以访问教育材料，与同行分享案例和经验。我们的教育计划的目的是增加CTO患者的治疗成功率，手术高成功率不应只局限于少数CTO专家。（图1）

　　图1. OCT教育培训计划模式

　　Chronic total occlusions (CTO) of coronary arteries not only represent a significant percentage of lesions found in patients undergoing coronary angiography for cardiac chest pain (between 18-30%)， but， more importantly， they remain a strong predictor of failed revascularization. With coronary bypass surgery， one year patency for saphenous vein grafts (SVG) attached to a CTO has been less than 40%.
　　So why are CTO patients treated with medication or CABG more frequently than with PCI? The answer may be partly explained by the historically low success rates achieved by PCI (60% in highly selected cases). Despite significant advances by a small group of expert operators (success rates in excess of 95% in unselected cases)， many view CTO PCI as a procedure impossible to master. One reason for this is the continued evolution and refinement of both techniques and equipment. A more fundamental hurdle， though， is the lack， till now， of structured training programs.
　　For a training program to succeed it must be teachable， reproducible， and delivered through a variety of educational methods. Three basic skillsets underpin the “hybrid” CTO platform:
　　Antegrade wiring skills – These are most analogous to “traditional” PCI.
　　Dissection re-entry skills – Dedicated equipment (crossboss blunt dissection catheter， stingray re-entry balloon) is used to traverse the CTO in the sub-intimal plane and then re-enter the distal true lumen.
　　Retrograde skills – The collateral circulation is used to access the distal vessel and disobliterate the CTO.
　　These skillsets are complementary， their use determined by case anatomy and a combination of predetermined and procedural factors. A key objective is for the procedure to be efficient， both in terms of time and the use of resources， including radiation and contrast. Whilst a foundation of good coronary interventional skills is important for a dedicated CTO operator， these additional skillsets have little in common with conventional PCI. As such， the skills require clear， concept-based descriptions of rationale and technique. This is best done within a multifaceted educational platform.
　　At the base of this platform are larger meetings with live case demonstrations. These serve to illustrate what is technically feasible， but do not offer the space to focus on the specifics of technique. Dedicated CTO meetings are aimed at a smaller， more knowledgeable audience， but are still often live case focused and thus the teaching can be unpredictable and case dependent. To address the need for well-structured learning， we at CTO Fundamentals have introduced a series of 1 day workshops， based on multiple recorded live cases， but interspersed with a conceptual focus on key， problematic areas – allowing the time to address the parts of the procedure physicians have most trouble with. The final part of the educational jigsaw is one-to-one proctoring， where expert CTO physicians visit the cardiac lab and supervise local physicians， helping to introduce new techniques， providing reassurance and， where needed， interventional input. These building blocks need to be backed by the ready availability of reference material. At www.ctofundamentals.org physicians can access educational material and share cases and experience with a peer group. The aim of our educational program is to increase the amount of successfully treated patients with CTOs. High success rates should not be confined to a small minority of CTO experts.