Proctorship in Chronic Total Occlusion Percutaneous Coronary Intervention in Low- and Middle-Income Countries: Challenges, Ethics, and Safety Implications—A Perspective From High-Volume CTO PCI Proctors in Latin America

Abstract

Chronic total occlusion percutaneous coronary intervention (CTO PCI) has evolved into a safe and effective revascularization strategy when performed by experienced operators in adequately resourced centers. Proctorship has accelerated learning curves, improved procedural success, and reinforced safety during early program development. However, available evidence derives predominantly from high-income countries with relatively uniform infrastructure, device availability, and team expertise.

In low- and middle-income countries (LMICs), particularly Latin America, CTO PCI proctorship operates within a markedly heterogeneous landscape characterized by variable institutional infrastructure, inconsistent access to safety devices, limited hemodynamic support, and wide disparities in operator experience. Under these conditions, the proctor’s role extends beyond technical mentorship to encompass real-time safety oversight, active procedural participation, ethical stewardship, and mitigation of system-level vulnerabilities.

This perspective explores the contemporary role of CTO PCI proctorship in LMICs, focusing on structural constraints, operator heterogeneity, recurrent procedural pitfalls, human factors, and ethical considerations. We propose a regionalized, center-focused model as a more sustainable strategy for capacity building, patient safety, and long-term program development. Although grounded in Latin American experience, the structural challenges and proposed solutions are broadly applicable to any setting where procedural complexity outpaces institutional readiness.