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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"
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.
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).
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 cardiologists Dr. Robert W. Yeh and Dr. Hector Tamez Aguilar, 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.
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.
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 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
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.