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Chronic Total Occlusion Treatment

Sophisticated procedure can reverse CTO, even after other treatments have failed

A pioneering new treatment at Tulane Medical Center offers hope to patients with a life-threatening condition that blocks blood flow to the heart.

Chronic total occlusion percutaneous coronary intervention is a minimally invasive procedure for people with chronic total occlusion, or CTO. With CTO, one or both of your coronary arteries becomes completely blocked.

If you’ve been diagnosed with CTO, and have been told your condition is too difficult to treat or treatment would be too risky, Tulane’s interventional cardiologists may be able to help. Thanks to their advanced training and unique experience treating patients with complex CTO, they have successfully treated many patients who thought they had run out of options.

This procedure is highly effective, but not widely available. In fact, Tulane Medical Center is one of the few centers in the country to offer it. Patients with CTO come to the hospital from across the Gulf South region and beyond for treatment by our interventional cardiologists.

To make this treatment accessible to more patients, our doctors travel to other U.S. hospitals to train their peers.

Your coronary arteries are the two main blood vessels that carry blood to your heart. If they become damaged or diseased, your heart may no longer receive all of the blood and oxygen it needs to work properly.

Coronary artery disease [link to http://tulanehealthcare.com/hl/?/11986/Coronary-artery-disease] occurs when one or more of your coronary arteries become clogged with plaque, a sticky substance made up of cholesterol and other materials. Over time, your coronary arteries may become so clogged with plaque that blood has a hard time flowing through them.

Chronic total occlusion is a type of coronary artery disease. People are diagnosed with CTO after one of their coronary arteries becomes completely blocked, and the blockage remains in place for longer than three months.

If one of your coronary arteries becomes blocked, your heart is receiving less blood – and therefore, less oxygen – than normal.

Blood may continue to reach your heart through your other coronary artery. Your heart may also make up for the blockage by creating additional small blood vessels which detour around the blockage. Blood can still reach the heart through these tiny new vessels, but not as easily, and you may begin to notice symptoms during exercise or when you feel stressed or anxious.

Symptoms of CTO include:

  • Chest pain (angina)
  • Shortness of breath
  • Abnormal heart rhythm (arrhythmia)

If left untreated, CTO can weaken the heart muscle, leading to heart failure or a heart attack.

In the past, treatment options for CTO were limited to medication (to relieve symptoms), coronary angioplasty and stenting, or a type of open heart surgery called coronary artery bypass grafting (CABG).

Tulane’s doctors continue to perform these traditional CTO treatments, because they are safe and effective options for many patients. However, some patients do not benefit from these procedures.

For example, conventional angioplasty and stenting techniques may not work if a blockage is especially long, or surrounded by hard calcium deposits or fibrous tissue.

Other patients may be too high-risk for open heart surgery due to their age or other medical conditions.

People who tried these treatments without success, or who were too high risk for surgery, were historically left with no other options.

Fortunately, during the last couple of years doctors have perfected a minimally invasive new treatment for CTO. The full name for the procedure is chronic total occlusion percutaneous coronary intervention, or CTO PCI.

With this procedure, it’s now possible for even high-risk patients to reverse their disease and live symptom-free.

The CTO PCI technique shares similarities with regular coronary angioplasty and stenting.

Both procedures allow doctors to guide a small, flexible tube (catheter) through your blood vessels until it reaches the blocked artery. And both procedures allow doctors to widen the artery (balloon angioplasty) and then insert tiny mesh tubes called stents that keep the artery propped open.

What makes CTO PCI so special is its use of new devices – including the next generation of tiny coronary guide wires – and surgical techniques that allow doctors to access blockages from several sides. For instance:

  • Doctors can now access a blockage by steering a guide wire through the small new blood vessels that have formed around the blockage.
  • • Doctors no longer have to tunnel through a difficult blockage to insert stents. Artery walls are made up of three layers of tissue. Doctors can carefully pierce the “skin” of the artery until a guide wire has reached the middle of those three layers. They can push the guide wire between the layers of tissue, then re-enter the hollow part of the blood vessel and place stents on both sides of the blockage.

Among all the interventional cardiologists in the U.S., about two percent – including Tulane physicians Nidal Abi Rafeh, MD, and Owen Mogabgab, MD – are qualified to perform the full range of CTO PCI procedures.

Dr. Abi Rafeh and Dr. Mogabgab are performing CTO PCI with a success rate between 85 and 90 percent, with a complication rate of less than two percent. This complication rate is equal to the national average.

Learn more about chronic total occlusion percutaneous coronary intervention.

If you would like to refer a patient for evaluation and potential treatment – or you are interested in CTO PCI training opportunities – please call (504) 988-6113.

Dr. Nidal Abi Rafeh

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