Revascularization Strategies for Ostial Left Anterior Descending Artery Chronic Total Occlusion: A Comprehensive Review

Chronic total occlusion (CTO) is encountered in about one quarter of patients undergoing coronary angiography and is associated with significant clinical and technical revascularization challenges. Among CTOs, ostial left anterior descending (LAD) occlusion represents a rare and particularly high-risk subset, owing to the large myocardial territory at risk and the unique anatomical and procedural difficulties encountered. These include ambiguous lesion morphology, heavy calcification, lack of a clear entry point, and increased risk of complications during revascularization. Data on optimal management remain scarce, with limited comparative evidence between different percutaneous coronary intervention (PCI) approaches, or regarding the comparison between PCI and coronary artery bypass grafting in this subset of patients. This comprehensive review synthesizes the current literature on the management of ostial LAD CTO, highlights procedural strategies and outcomes, and identifies existing knowledge gaps to guide clinical decision-making and future research. Available evidence suggests that the antegrade approach is generally preferred in less complex lesions, while retrograde strategies are reserved for stumpless, calcified, or anatomically complex occlusions. However, the absence of prospective randomized trials and the lack of dedicated comparisons between PCI and coronary artery bypass grafting in this population represent major limitations. Future large-scale studies are warranted to establish standardized treatment algorithms and define the optimal revascularization strategy for ostial LAD CTO.