Angioplasty for Chronic Total Occlusions (CTOs)
Sep 29, 2017, 12:10:00 PM
Chronic Total occlusions (CTOs) are defined as completely blocked arteries where the blockages have been known to be present for three months or more. The heart muscle supplied by the blocked artery suffers damage due to the absence of blood supply. In many cases, such damage is partial since collateral blood vessels arise from neighbouring arteries to supply the affected area. The collateral blood flow serves to keep the muscle alive, but the muscle function remains poor.
If the blood supply to these areas can be restored, the cardiac muscle function would improve. This can be done by means of bypass surgery or by angioplasty and stenting. It follows therefore, that angioplasty for a CTO should be attempted only if the vessel serves a significant area of myocardium that is dysfunctional but likely to improve after restoration of the blood supply.
Differences from a routine angioplasty
As opposed to a routine angioplasty, there is no path for the guidewire to track since the blockage is 100% in severity (Figures 1,2,3,4). The blockage length may be very long. In addition, the vessel course is not often clear. The beginning and end of the CTO segment are not often well defined. The vessel beyond the CTO may not be seen properly. A lot of calcium can get deposited, leading to a lot of difficulties while doing angioplasty.
Thus, a CTO angioplasty is more difficult, consumes more time for the procedure, more contrast agent usage, needs extra skill on the part of the operator, usage of specialized hardware (special guiding catheters, guidewires, devices, balloons, microcatheters, etc), special techniques, extra radiation and is usually costlier than the average angioplasty.
Techniques
There are two coronary arteries that supply blood to the heart muscle. Bilateral, simultaneous injections are needed to delineate the CTO segment. A careful study of the angiogram is done before the procedure to plan the approach. Guiding catheters of the appropriate size are chosen carefully so that adequate support is obtained during the procedure. Microcatheters are small tubes that can go inside the guiding catheter and can carry the guidewire. These lend support to the guidewires and can be used to change guidewires in between. Special guidewires of different tip strengths and other characteristics are available and chosen depending on the nature of the CTO segment. Small size balloons are available that can squeeze inside the toughest CTO lesion. Other specialised devices like Tornus, IVUS, rotablation may be needed at times.
Commonly, the antegrade approach is used similar to conventional angioplasty. The advent and development of retrograde angioplasty techniques have yielded better success rates.
Retrograde Angioplasty
While conventional angioplasty utilises an antegrade approach (passing a wire from the front or beginning of the CTO to reach the end/back of the lesion), a approach utilizes the collateral vessels that supply the coronary artery beyond the CTO to reach the end of the CTO segment and crosses from behind to front. Retrograde and antegrade approaches are often combined nowadays in a hybrid fashion to enhance success rates (figures 5,6,7,8).
Necessarily, the procedure is more complex, specialised, and needs special hardware, techniques and skills in crossing tiny collateral channels safely and performing the different steps of the angioplasty.
The techniques were conceived and refined by Japanese operators, who are currently acknowledged as grandmasters in this field. The techniques have been studied extensively and have been adopted all over the world. However, since it is a difficult procedure, there are only a few dedicated and trained operators in certain centres who can perform this on a regular basis. Aster Medcity at Kochi, India is one such institute where retrograde techniques are being utilised whenever needed.
Success rates
Success rates differ depending on the centre and the expertise available. While many Indian centres average a success rate between 50-65%, West European and American centres average 60-70%, and Japanese/ South Korean centres have a high average of 85% success rates in these complex cases. There are individual operators and centres that can claim a very high success rate of 95%. At Aster Medcity, we are proud to have an average success rate of 91%. The higher success rates are due to adoption of newer techniques and hardware including hybrid/retrograde angioplasty, dedicated extra time (presence of 3 cathlabs and reduced time constraints), high quality/low radiation cathlabs with large sized monitors, and trained staff/technicians/doctors. Long term results are extremely good, as reported in many studies (Figure 9).
Complications/Failures
Failure to cross the CTO segment with a guidewire is the commonest cause of failure. Other reasons include inability to track even the smallest balloon across the lesion or to stent the segment.
Complications seen are comparable to other routine angioplasties and include local bleeding, pain, swelling, breathlessness and occasional chest discomfort. Rarely, arrhythmias, artery perforations and even death are reported. Radiation hazards and contrast nephropathy have to be watched for and precautions should be taken for prevention.
CTO Angioplasty remains as the “Final Frontier” of coronary interventions. Newer techniques and hardware have vastly improved the success rates of these complex procedures. Careful and skilled adoption of these will result in better outcomes for patients.
Figure 1. CTO PRE
Figure 2. CTO POST
Figure 3. STENOSIS PREsept-30-3.jpgG
Figure 4. STENOSIS POSTsept-30-4.jpg
Figure 5. RETRO STEP SEPTAL CROSSING
Figure 6. RETRO STEP CTO CROSSING
Figure 7. RETRO STEP LOOP
Figure 8. CTO POST STENTING
Figure 9. COMPARISON
Related Articles
DO YOU HAVE A MIGRAINE HEADACHE & CAN IT CAUSE DIZZINESS:-
Jul 22, 2020, 6:41:00 AM
Lifestyle Choices : Understanding dilemmas of working women
Jun 16, 2020, 4:09:00 AM
What is limb reconstruction ?
May 25, 2020, 8:52:00 AM
WHAT TO DO IF YOU HAVE AN ABNORMAL FOETAL ECHO?
May 25, 2020, 8:51:00 AM
NON-SURGICAL MANAGEMENT OF CONGENITAL HEART DISEASES
May 25, 2020, 8:47:00 AM
How to take care of your health amidst COVID 19 pandemic
May 25, 2020, 8:43:00 AM
ABDOMINOPLASTY
Oct 14, 2019, 4:08:00 AM
GYNECOMASTIA
Oct 2, 2019, 4:04:00 AM
Congenital Heart Disease (CHD): What You Should Know
Sep 27, 2019, 6:51:00 AM
Dementia and Alzheimer’s Disease
Sep 23, 2019, 5:58:00 AM
Cosmetic Surgeries After Weight loss
Sep 18, 2019, 4:10:00 AM
High Blood Pressure and Your Health
May 20, 2019, 8:30:00 AM
Glucose Meters are Your Ally
Jul 11, 2018, 6:30:00 PM
Chemical Peel: Discover Radiant, Youthful Skin
Jun 26, 2018, 6:30:00 AM
Scoliosis In Children: How Corrective Surgery Can Transform Lives
Jun 25, 2018, 6:00:00 AM
Nonalcoholic Fatty Liver Disease (NAFLD): A Growing Epidemic in Kerala
Jun 12, 2018, 6:00:00 AM
NIPAH VIRUS INFECTION: BE INFORMED, BE SAFE
May 25, 2018, 6:00:00 AM
World Health Day 2018
Apr 6, 2018, 6:00:00 AM
Understanding Autism Helps Early Detection
Mar 29, 2018, 5:30:00 AM
Have The Right Amount Of Carbohydrates And Fats To Keep Your Heart Healthy
Mar 20, 2018, 5:30:00 AM
Cancer In The Elderly: Adopting A Holistic Approach
Mar 14, 2018, 5:30:00 AM
Women And Kidney Diseases
Mar 7, 2018, 5:30:00 AM
PCOS IN ADOLESCENTS : AN ENIGMA
Feb 15, 2018, 5:30:00 AM
Epilepsy: The Reality
Feb 9, 2018, 5:30:00 AM
Cancer- no more a crab!
Feb 2, 2018, 5:30:00 AM
Pulmonary Rehabilitation: Helping People With Lung Diseases Live An Active Life
Jan 17, 2018, 3:00:00 PM
Obesity In Indians
Nov 24, 2017, 2:00:00 PM
Diabetes- What We Should Know?
Nov 14, 2017, 2:00:00 PM
Pneumonia: What You Should Know?
Nov 11, 2017, 1:30:00 PM
9 Ways To Prevent Neck Pain
Oct 17, 2017, 12:30:00 PM
The Simple Step To Good Health
Oct 12, 2017, 12:30:00 PM
Understanding Alzheimers disease
Sep 21, 2017, 12:00:00 AM
TAKE A MINUTE, CHANGE A LIFE – SUICIDE PREVENTION AND YOU
Sep 9, 2017, 12:00:00 PM
Polycystic Ovarian Disease
Aug 30, 2017, 12:00:00 PM
Cancer Of The Cervix And How To Prevent It
Aug 19, 2017, 12:00:00 PM
Key Hole Spine Surgery: Making Spine Surgery Easier
Jul 28, 2017, 12:00:00 PM
Vitiligo: What You Should Know
Jun 29, 2017, 12:00:00 PM
Kidney Transplantation - A Second Chance At Life
Jun 27, 2017, 12:00:00 PM
Dialysis: A Life Sustaining Treatment For End Stage Kidney Failure Patients
Jun 19, 2017, 12:00:00 AM
Understanding Carotid Endarterectomy
Jun 13, 2017, 12:00:00 PM
Laparoscopic Surgery: What To Expect
Jun 2, 2017, 12:00:00 PM
Endoscopic Skull Base Surgery
Jun 1, 2017, 12:00:00 PM
Back Pain In Children: Never Ignore The Problem
May 31, 2017, 12:00:00 PM
The Diabetic Foot: A Surgical Perspective
May 30, 2017, 12:00:00 PM
Chronic Kidney Disease: The Silent Killer
Apr 20, 2017, 12:00:00 PM
Laser Surgery: The Effective Way To Treat Prostate Enlargement
Apr 19, 2017, 12:00:00 PM
Male Infertility: What You Should Know
Apr 5, 2017, 11:30:00 AM
Prostate Cancer: Ten Facts You Should Know
Apr 4, 2017, 11:30:00 AM
Walking on metal knees
Feb 22, 2017, 10:30:00 AM
Are You Sleeping Well?
Feb 21, 2017, 10:00:00 AM
Complex Coronary Angioplasty
Feb 20, 2017, 10:30:00 AM
Good Mental Health: An Overview
Feb 15, 2017, 10:30:00 AM
How does ‘bad’ cholesterol affect brain function?
Sep 6, 2016, 10:30:00 AM
Some Types of Blood Pressure Medications
Sep 6, 2016, 10:00:00 AM
IBD: Do you know the signs and symptoms?
May 31, 2016, 10:00:00 AM
Colorectal Cancer: What You Should Know
May 26, 2016, 10:00:00 AM
Healthy tips for your heart’s sake
Mar 17, 2016, 10:12:00 AM
Adding years to life after a coronary artery bypass surgery
Mar 10, 2016, 10:09:00 AM
What you need to know about osteoarthritis
Mar 4, 2016, 10:00:00 AM
Tetanus : what you should know
Mar 25, 2015, 10:00:00 AM
Stomach Cancer : Be Informed
Mar 19, 2015, 10:00:00 AM
Depression : Overcome it!
Mar 17, 2015, 10:00:00 AM
Smile healthy
Mar 11, 2015, 10:00:00 AM
Chicken Pox : How to manage the infection
Mar 9, 2015, 9:30:00 AM
Gastric Ulceration - Causes, Risk Factors and Symptoms
Mar 2, 2015, 9:30:00 AM
Lung Cancer: Symptoms, Causes and Treatments
Feb 26, 2015, 9:30:00 PM
Neck Pain: Symptoms, Causes and Treatment
Feb 25, 2015, 9:21:00 AM
PET/CT Scan: A New World of Diagnosing and Treating Patients
Feb 23, 2015, 9:30:00 PM
All You Need To Know About Cervical Spondylosis
Feb 18, 2015, 9:30:00 PM
Why do Panic Attacks Happen?
Feb 17, 2015, 6:30:00 PM
Malnutrition : facts you should know
Feb 12, 2015, 6:30:00 PM
Advanced medical linear accelerators help fight cancer faster, smarter and with precision
Feb 4, 2015, 6:30:00 PM
February 4: World Cancer Day
Feb 3, 2015, 9:00:00 PM
Breast Cancer: Symptoms, Causes and Risk Factors
Feb 2, 2015, 8:51:00 AM
Bells Palsy: Symptoms, Causes and Risk Factors
Jan 26, 2015, 6:30:00 PM
Changing The Experience Of Surgery
Jan 23, 2015, 8:34:00 AM
Tuberculosis: Causes, Symptoms and Prevention
Jan 21, 2015, 8:31:00 AM
Health Tips for Pregnant Women
Jan 16, 2015, 7:34:00 AM
Tips to tackle burns instantly and minimize scarring
Jan 12, 2015, 7:27:00 AM
Dengue : Stay Protected
Jan 7, 2015, 6:47:00 AM
Rabies: Causes, Symptoms and Protection
Jan 5, 2015, 6:46:00 AM
Dyslexia Guide for Parents and Teachers
Dec 30, 2014, 6:45:00 AM
Body Dysmorphic Disorder: Signs, Triggers and Remedies
Dec 22, 2014, 6:44:00 AM
Lower back pain: Causes and Symptoms
Dec 19, 2014, 6:43:00 AM
Bronchitis: Symptoms, Causes and Precautions
Dec 16, 2014, 6:41:00 AM
How To Deal With Allergies
Dec 11, 2014, 6:40:00 AM
Does Prolonged Cold Indicate A Sinus Infection?
Dec 5, 2014, 6:30:00 AM
What to expect from a Knee Replacement Treatment?
Dec 3, 2014, 6:29:00 AM
World AIDS Day - December 1
Dec 1, 2014, 6:28:00 AM
Malaria – Symptoms, Causes and Facts
Nov 27, 2014, 6:27:00 AM
Keep your home germ-free
Nov 25, 2014, 6:26:00 AM
Tackling Dandruff
Nov 19, 2014, 6:24:00 AM
Tips to stay healthy during winters
Nov 17, 2014, 6:22:00 AM
Healthy living and Diabetes
Nov 14, 2014, 6:20:00 AM
Breast-feeding reduces the risk of diabetes in children
Nov 12, 2014, 6:19:00 AM
Schizophrenia : Symptoms, Causes and Myths
Nov 10, 2014, 6:18:00 AM
Asthma : Causes, Symptoms & Self-Help Tips
Nov 4, 2014, 6:17:00 AM
Vaccination : keep your child healthy
Oct 31, 2014, 5:58:00 AM
Take care - children tend to swallow dangerous objects!
Oct 28, 2014, 5:39:00 AM
5 signs of ear infection in children
Oct 25, 2014, 5:38:00 AM
Celebrate a healthy and safe Diwali!
Oct 22, 2014, 5:36:00 AM
October 20 : World Osteoporosis Day
Oct 20, 2014, 5:35:00 AM
How to avoid feeling sleepy in the afternoon.
Oct 17, 2014, 5:05:00 AM
A great day begins with a healthy breakfast
Oct 15, 2014, 5:04:00 AM
World Arthritis Day: Get a free check-up* at Aster Medcity
Oct 11, 2014, 6:30:00 PM
Understanding ADHD (Attention Deficit Hyperactivity Disorder)
Oct 10, 2014, 11:11:00 AM
Protect your hair against sun damage
Oct 7, 2014, 11:03:00 AM
Migraine – Symptoms, Triggers and Treatment
Oct 1, 2014, 11:02:00 AM
Call Aster Heartline: Start caring for your heart
Sep 29, 2014, 11:01:00 AM
Only you can take care of yourself.
Sep 24, 2014, 11:00:00 AM
Are demands of modern life making women unhealthier?
Sep 22, 2014, 10:59:00 AM
kidney-stones-causes-and-remedies
Sep 19, 2014, 10:51:00 AM
Hepatitis A and B – Symptoms, Transmission and Prevention
Sep 17, 2014, 10:50:00 AM
Sweet fact: Chocolates are good for you.
Sep 15, 2014, 10:49:00 AM
Too strict on your kids? They can become obese!
Sep 10, 2014, 10:48:00 AM
Are you a diabetic? Make sure you don't fall prey to these 7 problems.
Sep 8, 2014, 6:41:00 AM
7 Fertility Myths Couples Need to Stop Believing
Sep 5, 2014, 6:40:00 AM
May your eyes live on.
Aug 27, 2014, 6:39:00 AM
10 myths on eye donation: let’s see the reality!
Aug 8, 2014, 6:38:00 AM
