Percutaneous Coronary Intervention (PCI) of Chronic Total Occlusions (CTOs)

According to the American Heart Association chronic coronary artery disease (CAD) is estimated to affect 16.8 million people in the United States.

Evolving therapeutic options at the Mat Gaberty Heart Center at McLaren Macomb.

Chronic total occlusion of the coronary artery
Chronic total occlusion (CTO) is defined as a 100% blockage in a coronary artery with TIMI 0 flow (no antegrade flow beyond point of occlusion) for at least a three month duration. Patients with CTO typically have collateralization of the distal vessel on coronary angiography, but these collaterals may not provide sufficient blood flow to the myocardial bed, resulting in ischemia and anginal symptoms. Among patients who have a clinical indication for coronary angiography, the incidence of CTO has been reported to be as high as 15% to 30%. Symptoms of CTO can include angina or chest pain, pain in the upper body, arms, jaw pain, shortness of breath, dyspnea or unusual fatigue.

Most patients with CTO who have symptoms as noted above have traditionally required coronary artery bypass graft (CABG) surgery to clear the blockage. In the past, total blockages of the coronary artery have been difficult to clear with interventional procedures.

Percutaneous coronary intervention (PCI) of chronic total occlusions (CTOs)
Percutaneous coronary intervention (PCI) of chronic total occlusions (CTOs) is a rapidly developing field. Critics of CTO revascularization generally perceive that symptoms are easily controlled with medications and CTO vessels have no impact on quality of life or survival. However, it is becoming increasingly evident that there are patients who continue to experience lifestyle limiting symptoms despite optimal medical therapy for angina. Further consideration for CTO revascularization is evolving in light of two important factors: 1) whether revascularization will provide the patient with quality of life benefit, improved survival, or both, and 2) which modality will provide the most durable result at the lowest up-front risk. Furthermore several studies have reported significant improvement in QOL metrics following successful CTO recanalization.

About the procedure
New advanced technology ("hybrid" percutaneous algorithm) developed by an innovative consortium of cardiologists provides a contemporary approach for percutaneous coronary interventions for CTO. Two guide catheters are placed to facilitate seamless transition between antegrade wire-based, antegrade dissection re-entry-based and retrograde (wire or dissection re-entry) techniques: the "hybrid" interventional strategy. After dual coronary injection is performed, four angiographic parameters are assessed: 1) clear understanding of location of the proximal cap using angiography or intravascular ultrasonography, 2) lesion length, 3) presence of branches, as well as size and quality of the target vessel at the distal cap, and 4) suitability of collaterals for retrograde techniques. On the basis of these four characteristics, an initial strategy and rank order hierarchy for technical approaches is established. Radiation exposure, contrast utilization and procedure time are monitored throughout the procedure, and thresholds are established for intraprocedural strategy conversion to maximize safety, efficiency and effectiveness.

"A number of studies have reported significant improvements in quality of life measurements after the procedure," said M. Blair DeYoung, DO, interventional cardiologist, McLaren Macomb. "With increased blood flow comes fewer symptoms, leading to a more enjoyable life."

Candidates who may be eligible for minimally-invasive treatment of their CTO include:
"¢ Patients with 100% blockages of their coronary artery and severe symptoms (such as angina) who are not candidates for bypass surgery.
"¢ Patients who have already had bypass surgery and have an artery that has reclosed.
"¢ Patients with a CTO in only one artery who otherwise have healthy arteries.

Benefits of CTO recanalization:
"¢ Improve symptoms of angina and dyspnea
"¢ Decrease need for coronary artery bypass surgery
"¢ Decrease the need for anti-anginal medications
"¢ Improve survival compared to that of patients with incomplete revascularization
"¢ Improve left ventricular function
"¢ Decrease substrate for arrhythmias
"¢ Improve tolerance of future acute coronary syndrome events

The goal is to get rid of a patient's angina, remove them off any medications they may be taking to manage their CTO and return them to living an active lifestyle.

The following physicians perform chronic total occlusion of the coronary artery at the Mat Gaberty Heart Center at McLaren Macomb.

M. Blair DeYoung, DO
Board Certified in Interventional Cardiology

Sibin Zacharias, MD
Board Certified in Interventional Cardiology