PCI for Chronic Total Occlusion

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 (Route 2).
• 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.

If you have chronic total occlusion of the coronary arteries, you may have shortness of breath of chest discomfort. You may also experience depression and a decreased quality of life.

You should first be treated with medications to see if those alone are sufficient to alleviate these symptoms.

If you continue to have symptoms impacting your quality of life, having a procedure to open the CTO can be considered. The objective of a percutaneous coronary intervention (PCI) is symptom control.

Before the CTO procedure, your team will perform an extensive review of images and data about your condition, will discuss your options and work with you to establish specific goals.

In addition to Dr. Yeh, the team includes Dr. Duane Pinto, Dr. Eric Osborn and Dr. Hector Tamez Aguilar.

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 monitored.

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
• infection
• heart attack
• 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 first procedure.

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.

To request a consultation with us, please email us or call 617-632-7701. You should expect to hear back from us within two business days. Please provide the following information when you contact us:

• Full name
• Date of birth
• Referring physician (if any)
• Name(s) of your PCP and cardiologist
• Best phone number to reach you