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UPMC Experts Provide Successful Treatment for Chronic Coronary Total Occlusion Based on Years of Experience

September 15, 2021

Cardiovascular experts at the UPMC Heart and Vascular Institute have performed more than 500 percutaneous coronary interventions (PCIs) to treat patients with chronic coronary total occlusion (CTO), making UPMC a premier destination for CTO treatment. UPMC has a dedicated team of cardiologists, nurses, and staff that perform PCIs with success rates higher than national averages.  

Catalin Toma, MD, director, Interventional Cardiology at the Heart and Vascular Institute, and his colleagues at UPMC including A.J. Conrad Smith, MD, and Jeff Fowler, DO, have been performing these procedures over the past eight years.

CTO represents the extreme of the PCI-treatable coronary artery disease (CAD) spectrum, with 100% occlusion in one or more coronary artery present for months and often years. As these blockages form over time, collateral flow from the adjacent arteries keeps the myocardium alive, but this is often insufficient when the demands are higher, leading to symptoms.   

“CTOs present a unique set of challenges because of the chronicity and the completeness of the occlusion. It’s often difficult to navigate the occluded segment from point A proximal to point B distal,” Dr. Toma explains. “In these long lesions there is ambiguity in the trajectory of the guidewires that requires specific techniques to be solved safely and effectively.”

Treating CTOs with Medication and Endovascular Therapies

About 10% of CAD patients undergoing angiography have CTOs. Not all require an intervention – often these patients can be managed medically. The patients that benefit from CTO PCI are those who experience persistent anginal symptoms despite medical therapy, or patients with decreased performance of their left ventricular function in the presence of significant ischemia on non-invasive testing. 
Dr. Toma and his team use a set of algorithms and techniques defined as the hybrid approach to anticipate how to best reach the site of blockage in a completely occluded vessel. This approach helps the operator make a prediction of what method to attempt first based on various characteristics of the lesion. 

“For CTOs, we usually need two points of vascular access, unlike the typical angioplasty,” Dr. Toma says. “We cycle through a set of options depending on the anatomy. We start with what is likely to be the most successful approach, but because there are so many options and branching points, the procedure takes time. It’s not a scripted procedure that you do the same all the time.”

It’s common to start with an antegrade approach first, where specialized guidewires are advanced through the blockage from the proximal end. In longer lesions, due to ambiguity, subintimal tracking in the vessel wall is performed with re-entry in the true lumen distally. But this approach doesn’t work for every patient and occasionally the operator will need a retrograde approach to the site of occlusion via collateral channels. Performing CTO PCI on a patient can be a complex procedure, and care is required to perform the procedure within safety confines of limited radiation and contrast exposure.  

A Multidisciplinary Approach to CTO Treatment

Providing specialized therapy for CTO patients not only requires time and expertise, but also specialized equipment and a multidisciplinary team of cardiovascular experts. These resources at UPMC have allowed CTO treatment to advance over the course of several years with complication rates remaining low.

“Our catheterization lab nurses, technicians, staff, interventional fellows, and advanced practice providers are an important part of the success of CTO treatment at UPMC,” Dr. Toma says. 

Dr. Toma and his team have an above average (90%) procedural success rate with CTO PCIs, with a lower-than-average complication rate, based on data from the Progress CTO Registry (a registry comprised of health care centers around the world with dedicated CTO PCI programs). 

At UPMC, we hope to continue improving treatment options for CTO patients while maintaining successful outcomes across the UPMC network. 

To learn more about CTO treatment at the UPMC Heart and Vascular Institute or to refer a patient, please contact Emily Zann, CRNP, clinical program coordinator at 412-647-9560, or Nicole Katich, CRNP, at 412-864-0534.