Chronic Total Occlusion (CTO)

Chronic total occlusion is a 100% blockage in one or more of the arteries supplying blood, oxygen, and nutrients to your heart. These blockages are caused by the buildup of fatty deposits called plaque (doctors call this atherosclerosis). When the blockages become very hard and stone-like, they are called calcifications.

Chronic total occlusions are a severe type of coronary artery disease that can cause debilitating chest pain (also known as angina), shortness of breath, and fatigue. Without treatment, CTOs can significantly affect your quality of life.

CTO Risk Factors
These risk factors can increase your chances of developing a chronic total occlusion:

• Coronary artery disease
• Diabetes
• High blood pressure
• High cholesterol
• History of a heart attack
• History of heart bypass surgery
• Kidney disease
• Obesity
• Smoking or other tobacco use

Your doctor may recommend these tests to learn more about the location and extent of your chronic total occlusion.

Stress Scans
These tests use medications to increase blood flow to the heart and capture detailed images of the blockages.

• Cardiac stress MRI scan: magnets and radio waves create images.
• Myocardial perfusion PET stress scan: a radioactive tracer is injected through an IV to create 3D images.
• Nuclear stress test: a radioactive tracer is injected through an IV to create 2D images.

CT Coronary Angiogram
A thin, flexible tube is inserted into a vein in your arm. After a contrast dye is injected, a CT scan uses specialized X-rays to create images of your heart.

In the past, doctors have been hesitant to treat chronic total occlusions with percutaneous coronary intervention due to the risk of complications. Thanks to new tools, advanced techniques, and better training, CTO PCI is safe and more feasible and effective at restoring blood flow to closed arteries.

CTO PCI: What to Expect
CTO PCI takes place in a sterile procedure room, similar to an operating room, called a cardiac catheterization lab.

First, your doctor will make two small incisions, usually one in the wrist and one in the groin, to access major arteries.

Using intravascular ultrasound guidance, catheters are threaded through those blood vessels to your heart. Sophisticated tools, including tiny high-speed drills, shock waves, and lasers, are used to carefully break up and clear calcified blockages. Your doctor will use a tiny balloon to open narrowed portions of the artery, and a mesh tube called a stent will be inserted to keep the artery open.

Finally, the catheters are removed, and the two access incisions are stitched closed. Altogether, CTO PCI usually takes less than two hours, followed by a few hours of observation in the hospital. You should be able to return home the same day.

Highly Qualified Center
CTO PCI should only be performed at qualified centers like Duke where specialized interventional cardiologists called “CHIP operators” (CHIP stands for complex high-risk indicated procedure) have the necessary training and experience to perform CTO PCI.

Advanced Imaging
High-quality images help your doctor plan your procedure with incredible accuracy, which translates to better outcomes.

Team Approach to Care
Our interventional cardiologists partner with other Duke heart specialists, including general cardiologists, heart surgeons, and perfusionists, to ensure your heart health is covered from every angle. Before making a treatment recommendation, we discuss each person’s case in a group setting to determine which therapy gives you the best chance of a successful outcome.