Chronic Total Occlusion Treatments

Mount Sinai offers a number of treatment options for chronic total occlusion (CTO), which is a long, complex blockage composed of calcium and other fibrous materials obstructing a coronary artery for more than three months. Causing conditions that include ischemia, angina, and poor left ventricular function, CTO is a challenging type of blockage requiring the skill of an experienced interventionalist.

While the American College of Cardiology recommends a procedure called a coronary artery bypass graft (CABG) for cases involving CTO in more than two vessels, this highly-invasive surgery can pose a risk for elderly patients. As an alternative, minimally-invasive options are available in the form of a type of procedure called percutaneous coronary intervention (PCI), which involves threading a catheter fitted with a device (such as a stent, balloon, or grinding instrument) from a small incision in the groin or arm to the problem site in the heart, where it opens the blockage, restoring adequate blood flow.

Types of CTO Procedures

The following two types of PCI are used to treat CTO.

  • Antegrade (front-end) approach: Mount Sinai's success rate with the traditional antegrade PCI is approximately 80 percent, which bests the national average of approximately 60 percent, and recent technological advances, including the development of both "floppy" and "stiff" wires, have further increased that success rate.

  • Retrograde recanalization (back-end) approach: This novel method involves using two catheters inserted over guide wires in the groin and femoral arteries to penetrate the blockage from both ends to create a canal through which blood can flow. These wires access the blockage via collateral vessels (small vessels that enlarge when a CTO develops in order to detour blood flow around the blockage). When the blockage is breached by the wires, a balloon and stent are threaded to the CTO site to clear a channel lengthwise, restoring proper blood flow. The retrograde recanalization approach usually requires two procedures spaced six to eight weeks apart, and takes about twice the time to perform as the antegrade approach. It can be used for patients for whom the antegrade approach is ineffective.

By offering minimally invasive techniques, leading-edge technology, and a team of skilled interventional cardiologists, Mount Sinai is pleased to provide the best possible outcomes for patients coming to us for the treatment of chronic total occlusions.