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How to tunnel your way into the CTO and create your own coronary artery !

Posted Aug 27 2009 9:44pm

Opening the chronically occluded coronary(CTO)  artery  gives the ultimate sense of  achievement and satisfaction for the cardiologist.  Of course , the patient may  or may not share the same feeling  . . . ! There are simple  and  complex CTOs . Some CTOs are opened in few minutes ,  some fail even after  hours of manipulation . For successful CTO opening  both  hardware and technique  are equally important.

Now we understand , acquiring expertise   with one or two guidewires  and mastering  them  is the key to success. Frequent changing of guidewires and other hardware  has increased the complication.

Definition of success in CTO

Unfortunately cardiologists  have varied perception on this vital issue . Most believe opening a CTO is synonymous with success . Some perceive  even crossing a  CTO with a guidewire is  a partial  success ! Real success lies in providing  sustained  opening  and restoring flow till  the  micro circulatory level. Advancing the distal blood flow for a short distance at a low velocity   can not be termed a success . It must be ensured  all  the  branches of    opened coronary artery must be perfused . This is a tricky issue as we can only  guess the number  of branches it had , before getting occluded.

The other most important  factor in determining the success of CTO  opening is the status of distal microcirculation . A dead myocardium does not welcome  the blood flow ! .It simply rejects it and this results in lower grades of TIMI flow. This factor is  mainly responsible for the negative clinical  outcome of   major PCI trials( TOAT, COURAGE)

The newer devices are helping us to  achieve our goal .

  • Retrograde approach through collaterals
  • Sub initmal tracking of CTOs
  • Japanese have pioneered the CTO interventions

asahi tornus coroanry cto catheter chronic total occlusion

CTO PTCA PCI CAG  dr venkatesan coronary angiogram

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