UPMC Physician Resources

Case Study: Coronary Chronic Total Occlusion

Catalin Toma, MD and Conrad Smith, MD

The case study is of a 69-year-old man with diabetes mellitus, high cholesterol, hypertension, and coronary artery disease had two prior coronary bypass surgeries, the most recent in 2010 with LIMA-LAD. Over the past few years the patient developed progressive symptoms with daily exertional angina CCS class 3 despite maximal medical management. He was self-referred to us to evaluate treatment options.

The Evaluation

The patient’s EKG did not show any prior MI. The patient had a prior cardiac MRI which revealed significant viability in the anterior and inferior walls, but not in the lateral wall. Left ventricular function was moderately diminished with significant wall motion abnormality in the lateral inferior and inferoseptal walls and calculated ejection fraction of 43%. A coronary angiography was performed and revealed 90% mid LAD disease with patent LIMA to LAD; the OM1 was also 100% chronically occluded with an occluded vein graft and left-left collaterals; the RCA had 100% proximal chronic total occlusion (red arrow, panel 1) with occluded graft and collaterals from the LIMA via the LAD (blue arrow panel 2). 

Panel 1:   Panel 2:


Anatomy of a CTO PCI. A. The RCA is 100% occluded proximally (red arrow), with the dotted line indicating the course of the artery. B.Contralateral injection via the LIMA graft are used to visualize the collateral flow to the distal RCA; an anterograde wire escalation approach was initially attempted but failed to reach the distal vessel.

The Procedure and Results

Given the presence of significant viability by MRI in the inferior wall, and the limiting angina, we felt that the patient would benefit from a percutaneous intervention of the RCA CTO. An initial antegrade dissection reentry approach was unsuccessful. The team then wired the RCA retrograde through the LIMA graft and a septal perforator (panel 3). A controlled retrograde dissection and proximal re-entry technique was then employed to advance the retrograde wire from the collaterals back into the proximal RCA, which was then was externalized through the antegrade RCA guide. Angioplasty and placement of drug eluting stents was then performed, with good angiographic results (panel 4). The retrograde equipment was then removed and the final angiograms revealed no complications. The patient was discharged home the following day. At one-month followup he had only intermittent angina (CCS class 1) with significant reduction in nitroglycerin usage. His post procedure echo revealed normal EF.

Panel 3: Panel 4:


Anatomy of a CTO PCI. C. Next the RCA was wired retrogradely, via the collaterals from the LIMA-LAD, andthe wire externalized via the RCA guide catheter. D. Drug eluting stentswere placed using this wire with good angiographic results.

About UPMC’s CTO Program

As is typical of the patients seen in the UPMC Chronic Total Coronary Occlusion (CTO) Program, this patient had a very complex anatomy. Successful PCI for these CTOs requires mastery of several different PCI approaches, both antegrade and retrograde, with the capacity to quickly and timely adapt to the progress of the procedure. These cases are always done with a team of two attending physicians in a low radiation catheterization lab on a dedicated day of the week. The program has treated dozens of patients to date, achieving a good therapeutic response. When a percutaneous revascularization is truly not feasible, UPMC offers access to a comprehensive range of treatment options, such as surgical (redo) revascularization, EECP (Enhanced External Counterpulsation) therapy or participation in cell therapy trials.

We constantly adapt and alter approaches based on the progress of the procedure.