Clinician-to-Clinician Update Clinician-to-Clinician Update

New Angioplasty Procedures for Chronic Total Occlusion Provide Relief

May 2017

A technologically advanced angioplasty procedure is helping heart patients with chronic total occlusion (CTO).1 Traditionally, CTO might have been addressed through coronary artery bypass grafting or the blockage might have been deemed too complex for successful intervention. The condition, too, has been known to reemerge even after medicinal and surgical intervention. New approaches to CTO angioplasty, however, have shown promise, demonstrating success rates of 77%2 with low risk of complication. Contrary to the perception that patients with advanced CTO are out of treatment options, the approach can restore blood flow to arteries that may have been blocked for years.

CTO, the complete closure of a coronary artery for at least 3 months, results from the slow buildup of plaque. The condition is found in up to 30% of patients with suspected coronary artery disease who undergo a coronary angiogram.1, 2 In contrast to the acute loss of coronary blood flow during a heart attack, CTO develops gradually and can become resistant to antianginal medications. In addition, the hard plaque of a CTO is often impenetrable with the guide wires and balloons used in standard angioplasty. In the past, CTO patients at this stage had few options.3

May-2017-Heart-Care-Feature-Article-Main-Image
— Advances in guide wire and catheter technology have helped improve patient outcomes in angioplasty for chronic total occlusion.

New surgical approaches, new technology enabling more precise movement of guide wires and catheters, and innovative catheters are, however, extending treatment options. Among these are “reentry” and retrograde approaches. The approaches address a unique feature of occluding plaque: its tendency to be hard at the proximal end of the occlusion but more penetrable at and beyond the distal end. In reentry angioplasty, interventional cardiologists run special guide wires and/or catheters slowly within the artery wall and past the distal end of the occlusion, reentering the vessel from behind the blockage.1 In retrograde approaches, cardiologists approach the occluded artery via a different non-occluded artery and steer specially designed guide wires through connecting collateral vessels and into the patent segment of the occluded artery distal to the occlusion. Special microcatheters are then advanced over the guide wire until they reach the distal end of the occluded segment, which can be softer and better oriented for penetrating.

Before 2000, angioplasty for CTO was considered high risk because of the possibility of the guide wire perforating the coronary artery and causing a bleed.3 Since then, improvements in guide wire technology, techniques, and operator skill have driven the success rate from just over 65% in the early 2000s to 77% by 2011, while the risks have dropped. Total complication rate is below 3% when performed by trained interventionists who use angiography in assessing the occlusion and the latest approaches in addressing it.2 Extensive clinical evidence shows that successful CTO results in significant relief from angina and increased survival for up to 6 years.1, 3

As with many technically complex medical procedures, angioplasties conducted at centers that treat a high number of CTO cases provide better patient outcomes.1, 2 University of Minnesota Health Heart Care interventional cardiologists operate a dedicated high-volume CTO angioplasty suite where patients with the most complex CTOs can receive lasting relief from symptoms of coronary artery disease. In 2016, the success rate for patients undergoing CTO procedures at University of Minnesota Health locations was >90%.

References

  1. Shah, PB. Management of coronary chronic total occlusion. Circulation. 2011;123:1780-1784.
  2. Patel VG, Brayton KM, Tamayo A, et al. Angiographic success and procedural complications in patients undergoing percutaneous coronary chronic total occlusion interventions. JACC Cardiovasc Interv. 2013;6(2):128-136.
  3. Hoebers LP, Claessen BE, Dangas GD, et al. Contemporary overview and clinical perspective of chronic total occlusions. Nat Rev Cardiol. 2014;11(8):458-469.

When to refer

University of Minnesota Health Heart Care cardiologists diagnose and treat the full spectrum of structural heart diseases, including valve disease, coronary artery disease, and aortic stenosis or dissection. We offer a range of interventions for coronary artery blockages, including open or minimally invasive coronary artery bypass grafting and angioplasty. Our interventional cardiologists use percutaneous techniques such as angioplasty and stenting to treat patients with mild to severe symptoms of coronary artery disease. Our providers operate a dedicated high-volume angioplasty suite for the treatment of chronic total occlusion and have decades of experience in treating patients. University of Minnesota Health Heart Care cardiologists employ the latest surgical techniques and guide wire technology and are national experts in the diagnostic interpretation of cardiac angiograms.

Multidisciplinary, Collaborative Care

University of Minnesota Health Heart Care clinicians make a broad range of heart care specialties available to your patient. Our team includes interventional cardiologists, cardiac surgeons, radiologists, electrophysiologists, nurse practitioners, and pediatric cardiologists. Community clinicians who provide heart care to their patients are our most important partners. This essential partnership allows us to coordinate continuous care for patients with heart conditions through direct communication with you, the primary care clinician who directs care. Our goal is to work with each provider to treat and cure heart diseases in the community using our multidisciplinary combination of cutting-edge technology, evidence-based research, and collaborative care.

For more information about clinical trials visit studyfinder.umn.edu.

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