At your last appointment with your cardiologist, you were told you have a CTO, but what exactly is that? A chronic total occlusion, or CTO, is a relatively common condition. To explain what a CTO is and what it means for your health, let’s first zoom out to focus on how the heart works.
Your heart keeps your entire body functioning by pumping blood throughout the body in rhythm with your heartbeat. This role depends on blood getting to the heart in the first place.
The coronary arteries are responsible for ferrying blood to the heart. Optimally, these vessels are free and clear of obstructions so that blood can flow normally. However, these vital arteries often become blocked by fatty plaque buildup.
Many Americans have some level of buildup in their coronary arteries, with 18 million Americans having coronary artery disease. While many people have some level of plaque buildup, in some cases, a coronary artery can be completely blocked off. This is called chronic total occlusion (CTO).
What does it mean to have a CTO?
Anyone can be affected by a CTO, but these blockages are most common among those who have had coronary artery bypass graft (CABG) surgery in the past. Around 1-in-3 people who have coronary artery disease also have a CTO, but it will be close to half of patients after a CABG.Typically, after CABG, one can expect some of the bypasses to become blocked in the five to 15 years after the surgery. The artery that was supplied by the bypass often becomes a CTO in the meantime.
Whether or not you have already had a CABG, if you are diagnosed with a CTO, it means there is a complete blockage of one of your coronary arteries that has been there for at least three months. A complete blockage fully restricts blood from flowing to your heart, which can be life-threatening in some cases. While the artery is blocked, natural bypasses are providing flow to the heart muscle, as a spare well of the heart.
A chronic total occlusion can cause symptoms including chest pain, chest pressure, fatigue, nausea, shortness of breath, and pain in the upper arms and shoulders. More important, having a blocked coronary artery can lead to a heart attack.
Can a chronic total occlusion be treated?
A chronic total occlusion is typically diagnosed through a specialized type of imaging scan called a coronary angiogram, which uses contrast dye to highlight the arteries. If you are diagnosed with a CTO, there are multiple treatment options. The type that is right for you will vary depending on several factors, including whether you are experiencing symptoms and your overall health.
A coronary artery bypass graft (CABG) procedure may be recommended for someone who has never had that treatment. During CABG, a blood vessel, often a vein from the leg or an artery from the chest, is transplanted around the heart, bypassing the blocked artery and restoring blood flow. CABG is typically performed as an open-heart procedure, where the sternum is cut open to access the chest. While it may be a good option in someone who has other blockages in addition to the CTO, it often will not be possible to repeat CABG in someone who has already had several bypasses to their coronary arteries.
Patients who are frail or otherwise at higher risk of complications may also not be suitable candidates for CABG. In those cases, our team of expert providers at the Center for Complex Coronary Disease will offer an alternative treatment option, such as advanced percutaneous coronary intervention.
Percutaneous coronary intervention, also called PCI or angioplasty, is a minimally invasive procedure performed by an interventional cardiologist. During PCI, a tiny tube called a catheter is inserted into the body through the wrist or the groin and woven up to the heart with the aid of advanced, real-time intravascular imaging.
Once the catheter is in place in the blocked artery, a small balloon will be inflated, pushing plaque to the sides of the artery and restoring blood flow. After a path for blood flow is restored, a mesh stent will be put in place to keep the artery open.
Because a CTO fully blocks a coronary artery, a CTO PCI will be more complex than a traditional PCI. A specialized expert interventional cardiologist may need to use multiple pathways to access the blocked artery or guide the catheter through the walls of the artery to reopen it successfully.
While this requires a more intricate approach to the procedure, it is still minimally invasive, and patients are often discharged from the hospital within a day. The success rate in opening CTOs is above 90%, and the risk of complication is below 1% in most cases.
Next steps
Georgia Heart Institute offers innovative and advanced treatment options for higher-risk patients with CTOs or who are not candidate for CABG through the Center for Complex Coronary Disease. Call 770-219-4044 or click here to learn more.
Stephane Rinfret, MD, is director of complex coronary interventions at Georgia Heart Institute.