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Relief for patients with difficult heart blockages
Chronic total occlusion therapy offers patients a minimally invasive treatment for "coronary road blocks"
Watch George's story and learn more about CTO care.
Your heart, like any muscle in your body, requires sufficient blood flow to
supply oxygen and nutrients that allow it to function. Blockages can
develop in any of your three major heart arteries (coronary arteries).
These can lead to heart attacks, if they occur suddenly, or to chest
discomfort, if they occur more gradually.
Blockages are usually due to a build-up of fat and calcium
(atherosclerosis) that narrows the arteries. This condition is the number
one killer of men and women in developed countries.
Severe Blockage Symptoms
shortness of breath that usually worsens with activity
Risk Factors for Coronary Artery Disease
high blood pressure
a strong family history of heart disease
New Treatments for CTO
About 15 percent of patients with coronary artery blockages have an artery
that is 100 percent blocked. These blockages have usually been present for
months to years and are known as chronic total occlusions (CTO).
The nature of these blockages and the challenges of treating them are
highly complex. Historically, cardiologists had few minimally invasive
treatment options to offer. As a result, patients were often advised to
have open heart surgery or be treated with medications alone. This
frequently happens even today, leaving some patients with a severely
decreased quality of life.
In recent years, advances in interventional cardiology have resulted in new
minimally invasive treatments to open complex coronary blockages, including
CTOs. A small number of interventional cardiologists — about one percent of
those practicing in the U.S. — have the skills to perform these procedures.
Among these few are members of a team led by interventional cardiologist
Dr. Robert W. Yeh
at the CardioVascular Institute at BIDMC. The team specializes in
evaluating your condition and in using sophisticated new procedures to open
your complex blockages.
Interventional cardiologists treat coronary blockages with percutaneous
coronary interventions (PCI) — non-surgical procedures in which they gain
access to the heart through a tube or catheter inserted through a puncture
in the skin.
Most coronary blockages are partial, allowing some blood to still flow
through the artery.
As long as this is the case, it is easier for the cardiologist to deliver
routine therapeutic devices to the heart through the narrowed passageway.
The cardiologist uses a balloon-like device to widen the blockage and
places a metal mesh (stent) in the artery to keep it open. Patients
typically arrive at the hospital early, undergo a one- to two-hour
procedure, and return home a couple of hours later.
In contrast, if you have CTO, this means your arteries are 100 percent
blocked. There is no clear passageway for the doctor to pass devices
through the artery to open the blockage. The area of the heart that is
supplied by the blocked vessel is usually kept alive by new blood vessels
that grow from other areas (collateral arteries). These collaterals,
however, are often not sufficient to prevent you from having chest
discomfort or shortness of breath when exerting yourself.
Because of these features, opening a CTO requires a combination of
specialized devices and techniques, including:
Inserting tubes (catheters) into both the blocked artery and additional
arteries supplying the collateral arteries. This usually requires
entering two arteries in either your wrist or your groin.
Using stiffer wires to poke through your 100 percent blockage —
particularly if the blockage is short (Route 1)
Navigating around a longer blockage by tracking the catheter along
inside the exterior vessel wall and then going back into the vessel
Going backwards through your unblocked collateral-supplying vessel to
open the blocked artery from the back side, known as a retrograde
procedure (Route 3).
These procedures usually take two to four hours and require patients to be
monitored during an overnight stay in the hospital.
In specialized centers like ours, the overall success rate is between 80
and 90 percent, but it is realistic to expect that some cases are more
challenging than others.
Your procedure will be performed by two interventional cardiologists,
nurses and a technologist specially trained for this type of procedure. You
will be awake for most of the procedure.
Typically, one catheter is placed in your wrist and another in your groin,
although for more complex blockages, both catheters may be inserted in the
groins. After the procedure, the catheters will be removed. Usually,
patients stay one night in the hospital so that your progress can be
Safety is our number one priority. If during the procedure we see evidence
that the risk may outweigh the possible benefits, we may stop to discuss
this with you, your family and your heart doctor. Despite our best efforts,
complications can occur.
CTO PCI and routine PCI have similar complications, although they are more
common in CTO PCI. These may include:
bleeding at the access site (arm or groin)
kidney damage (usually temporary)
allergy to contrast dye or medications
damage to the arteries or the heart itself
For this reason, our team makes a careful examination of the specific risks
of the procedure and potential benefits for each patient. We will pursue
the best course of action based on shared decision-making by the patient
and the CTO PCI team.
Some 10 to 15 percent of patients may require a second session to fully
open their blockages. This usually happens six to eight weeks after the
After successful CTO PCI, most patients’ angina and quality of life
improve. Studies performed by Dr. Yeh and colleagues using data from a
nationwide data registry showed that patients who underwent successful CTO
PCI were likely to report improvement in their chest pain and shortness of
breath one year after the procedure.