Contrast modulation in chronic total occlusion percutaneous coronary intervention

Lorenzo Azzalini, Barry Uretsky, Emmanouil S Brilakis, Antonio Colombo, Mauro Carlino

Research output: Contribution to journalArticlepeer-review

8 Scopus citations


The intraplaque injection of contrast media in the recanalization of coronary chronic total occlusions (CTO) has witnessed a dynamic journey since its initial formulation. Contrast-guided subintimal tracking and re-entry (STAR) was the first contrast modulation technique for CTO percutaneous coronary intervention (PCI). With this technique, a forceful injection of a large volume of contrast (3–4 mL) was performed in order to achieve hydraulic recanalization of the vessel. This approach was associated with extensive vessel injury and unpredictable true lumen re-entry, which were in turn linked to high rates of restenosis on follow-up. In the subsequent iteration, called the “microchannel technique”, a smaller amount of contrast media (1 mL) was gently injected inside the plaque to modify its compliance by softening and recruiting loose tissue, which facilitated subsequent true-to-true lumen crossing with a polymer-jacketed wire along paths of least resistance. The microchannel technique has later evolved into what is currently known as the “Carlino technique”, where a minimal volume of contrast media (<0.5 mL) is gently injected inside the occlusion, with the goal of modifying plaque compliance to facilitate guidewire and microcatheter advancement through a fibrocalcific plaque. The Carlino technique is now widely utilized to allow negotiation of difficult-to-cross occlusions, particularly by the “hybrid operators”, with high success rates and low incidence of complications. The purpose of this article is to provide a historical perspective on the use of contrast modulation in CTO PCI, its pathophysiological basis, as well as technical recommendations on how and when to perform these maneuvers.

Original languageEnglish (US)
JournalCatheterization and Cardiovascular Interventions
StateAccepted/In press - Jan 1 2018


  • Carlino
  • chronic total occlusion
  • contrast
  • microinjection
  • percutaneous coronary intervention

ASJC Scopus subject areas

  • Radiology Nuclear Medicine and imaging
  • Cardiology and Cardiovascular Medicine


Dive into the research topics of 'Contrast modulation in chronic total occlusion percutaneous coronary intervention'. Together they form a unique fingerprint.

Cite this