Chronic Total Occlusion Treatment

What are the coronary arteries?

Our coronary arteries – blood vessels that wrap around the outside of the heart – have an important job: they carry oxygen-rich blood to the heart. Your heart muscle needs oxygen to stay healthy and work properly.

Certain lifestyle choices and medical problems often damage the coronary arteries. A sticky substance called plaque can build up and narrow the inside of these arteries, making it harder for blood to reach the heart. This narrowing is often called coronary artery disease, or CAD.

What is a chronic total occlusion?

Chronic total occlusion is an elaborate name for a straightforward problem. If you have CTO, it means one or more of your coronary arteries is completely blocked. However, treating a CTO has traditionally been not so straightforward.

CTOs are a common heart disorder and are present in approximately 20% of patients with CAD.

A groundbreaking new treatment available at VCU Health Pauley Heart Center helps many patients with chronic total occlusion (CTO) feel better and enjoy better quality of life.

Symptoms associated with chronic total occlusion

It can be frightening to learn you have CTO, especially if you’re struggling with frequent shortness of breath, angina (chest pain or tightness) or fatigue. These blockages can also induce arrhythmias (irregular heart beat) and heart failure. But you can also have hope, knowing life-changing care for complex coronary disease is available right here in Virginia.

Sever CAD can cause a complex coronary blockage

Over time, as more plaque builds up and CAD worsens, a coronary artery may become completely blocked. This is known as a coronary total occlusion.

If the blockage stays in place for three months or longer, it’s called CTO (chronic total occlusion). This is a life-threatening condition that deprives the heart of oxygen. Without proper treatment, CTO often leads to a poor quality of life and even more serious conditions such as heart failure.

Learn more about symptoms, complications and risk factors of CTO and other forms of coronary artery disease.

Expert care for chronic total occlusion

Whether you’re seeking CTO treatment for the first time or need a second opinion, you can count on our team for services and support that are second to none.

High-quality care for a hard-to-treat condition

Compared to moderate cases of coronary artery disease, where the blood vessel is only partially plugged, CTO is much harder to treat. Until now, CTO treatment options were limited.

Minimally invasive procedures called percutaneous coronary interventions (PCIs) are a good option for many people with mild CAD. But these same procedures – which include angioplasty and stenting – often do not work in people with CTO. That’s why doctors usually recommend a type of open-heart surgery called coronary artery bypass grafting (CABG).

CABG is an effective CTO treatment, but it is risky for some patients and includes a long recovery due to the invasiveness of surgery. Some people aren’t eligible for CABG because of age or other medical problems. Patients who are not candidates for CABG or traditional stent procedures have historically been told they have no choice but to live with their worsening symptoms. This is particularly frequent in patients who already have had CABG, as with time both the grafts and the coronary arteries can become totally occluded, and a second surgery is often high-risk.

Fortunately, game-changing new devices and techniques available at Pauley Heart Center can greatly reduce CTO symptoms and the risk of heart attack or heart failure. We’re home to one of the country’s leading experts on a treatment called chronic total occlusion percutaneous coronary intervention (CTO PCI), Dr. Lorenzo Azzalini . Thanks to this minimally invasive procedure, we successfully treat many CTO patients who thought they were out of options.

What makes new CTO treatment different

CTO PCI is similar to other interventional heart procedures. Instead of opening the chest, doctors guide catheters (thin, flexible tubes) through the body’s main blood vessels until they reach the heart. They use X-ray imaging and contrast solution (a special dye) to monitor their progress in real time.

When the coronary artery is only partially blocked, there is still space for catheters to travel through it. Doctors can then widen the artery with an inflated, balloon-tipped catheter (angioplasty) and permanently prop it open with one or more tiny mesh devices called stents.

In people with CTO, the artery is completely blocked and is often surrounded by tough, calcified tissue that’s hard to get through. Fortunately, the body often compensates for this blockage by creating tiny new arteries called collateral blood vessels. These vessels help blood detour around the blockage, so it still reaches your heart.

Thanks to miniature devices, including coronary guidewires, microcatheters, and re-entry devices, doctors no longer have to try and push through the blockage: a traditional approach that might work in non-completely blocked arteries but is unlikely to succeed in CTO. Instead, they approach the blockage in one of two ways: 1) through the network of collateral blood vessels (retrograde approach); or 2) through the layers of tissue that make up the artery wall (dissection/re-entry techniques).

Both approaches let your doctor place stents on the blockage. Not only are these approaches unique, but physicians at Pauley Heart Center can move through the collateral blood vessels using antegrade (forward moving) and new retrograde (backward moving) techniques. When used together, these highly specialized techniques maximize the likelihood of success, while maintaining a low risk for complications.

Risks of CTO PCI

CTO PCI in as an aggressive procedure used to treat a challenging condition. Like any interventional or surgical procedure, it has risks. These include:

• A tear in the tissue that makes up the artery wall (coronary perforation)
• Heart attack
• Injury in the vessel that gives collaterals to the blocked artery, during the retrograde approach
• Kidney damage caused by the contrast solution injected during the procedure (your risk is higher if you already have kidney disease)
• Radiation-induced skin lesions (CTO procedures are longer and use significantly higher radiation dose compared with conventional PCI)

To help reduce the risks of CTO PCI, we offer customized procedures for certain patients. These include:

• Performing separate, staged procedures to spread out the use of radiation and contrast solution, especially among patients with more than one blockage
• Using alternative intravascular imaging technology that doesn’t require contrast solution
• Using mechanical pumps to help with blood circulation, for people with reduced heart function

At Pauley Heart Center, our CTO PCI success rate averages 85-90% and our complication rate is around 2%. These rates compare very favorably to the national average (success rates of around 60%) and are in line with the best case series from specialized CTO operators worldwide.

Contact us

For patients

To schedule an appointment with a CTO specialist at Pauley Heart Center, please call (800) 762-6161, weekdays from 8 a.m. to 5 p.m., or request an appointment online.

For physicians

To refer a patient for further evaluation or potential CTO treatment, please call (804) 628-4327.