**9.3. The hybrid approach**

The hybrid algorithm depicted in **Figure 3** represents a combined strategy comprising AWE/ RWE and ADR/RDR techniques (**Table 3**) [194, 195]. The fundamental principles in hybrid procedures require a special mindset and great flexibility in the approach with the ability to perceive failure modes early to quickly change strategy and to come back to abandoned strategies, if necessary. Experienced CTO operators aim for efficiency and look for multiple strategies with several options and different techniques. This skillset can be taught and transferred with implementation of the hybrid algorithm, ideally in a broader setting with operators of different experience levels to improve technical success while maintaining low complication rates. The adoption of only a few strategies will limit the patients who can be treated on the basis of coronary anatomy [82, 176, 186, 196, 197].

**Figure 3.** The Hybrid Algorithm. Adapted from Ref. [194].


**Table 3.** Contemporary antegrade and retrograde techniques [195].
