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Posts Tagged ‘chronic total occlusion’

Japanese are the pioneers in CTO reopening .(I understand they do less   CABG surgeries  for  religious reasons ) CTO is the ultimate test for cardiologist patience .  it may  take  hours to open up a CTO (or even to abandon it .)  Here is a  success prediction tool from Japan .

cto score success in chronic total occlusion

j cto score  sheet

Source courtesy  : JACC: Cardiovascular Interventions Volume 4, Issue 2, February 2011

Reference

http://www.sciencedirect.com/science/article/pii/S193687981000912X

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chronic total occlusion cto tips and tricks

Answer :

While each one of the above factor appears very much important  morphology of the lesion is the  clear winner  ( Which includes , the content of the lesion , hardness , micro channels , thickness of the proximal and distal caps, the length and   tortuosity   of the CTO     ( which is invisible ) the collateral status will ultimately determine the success)

It is becoming increasingly clear  cardiologist expertise is getting less and  less important .

Finally ,  it must  be told to our  younger generation of cardiologists , crossing a  CTO and deploying a stent  is not synonymous with success .It should result in long term sustained distal flow and make a significant impact on the patients symptoms (If at all any !) and survival.

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Hi all ,

I get frequent comments about my blog. I do try to answer many of them . This is a very unique one , and it is making me think further.Since he has specifically wished his clinical data could be eye opener for others ,  I am jut posting it here . The comment was in response to my article  Who said coronary collateral circulation will not support exercise ?   here is  the extract

Dr. Venkatesan,

I read your blog with great interest and I think I may have something useful to contribute from my own personal experience. I am a 68 year old male with a long history of smoking (for fifty years), and a history of uncorrected hypertension over the years (it has been corrected to normal with medication for many years now). I am a non-smoker now for the past 18 months. I have PAD and a moderate aortic aneurysm of about 3.5CM (ascending and descending) which is being watched with regular vascular scans.
The common femoral arteries in both of my legs are nearly 100% occluded between my thighs and my knees, and yet my ankle and toe blood pressures (and my circulation in my ankles and feet) is almost normal. The reason for that is that according to the vascular scan, my deep femoral arteries are much larger caliber than normal with extensive vascular collateralization by passing the common femoral occlusions.
About twenty years ago before the PAD diagnosis, I realized that I had claudication in both of my calves when I walked a short distance. I expected this was being caused by an arterial blockage in my legs, so I went to the gym every day for about three years, and walked through the pain every day. I believe this contributed to the formation of the collaterals that have perhaps saved my legs and feet.
I also have heart disease, and had a fairly minor heart attack in 1999. No stents were placed nor angioplasty performed at that time. I recently had an arteriogram and cardiac stress MRI which showed that two of the three coronary arteries are now 100% occluded (apparently I had another cardiac event and did not know it). The cardiologist says that the LAD is in extremely good condition and has numerous collaterals branching from it. I have no symptoms whatever from all of this, except that my LVEF is low (about 35%). I walk at a very brisk pace six miles per day, five days per week, and I monitor my pulse rate with a pulse monitor when I walk. I keep my pulse between 115 and 120 which I calculate to be 80% of maximum for my age. I believe this cardio exercise / walking has also helped with the collateral formation, and I am hoping to bring the LVEF back up to a reasonable number with this exercise regimen.
My cardiologist has recommended an ICD, but I have decided against that since I have never had VT or VF or any other type of cardiac arrythmia (except for non-symptomatic PVC’s which I was born with).
I believe that I am the lucky recipient of good genetics to begin with, but also I am highly motivated now to take better care of myself, and know as much as I can about the conditions that I have. I plan to have an echocardiogram in six months to see if the LVEF numbers have improved, and I fully expect that they will have. I give credit to the smoking history for the vascular problems that I have including the cardiac problems. I am a lucky person I think, and suspect that not everyone has the fortunate ability to heal themselves the way I have.
I have asked for copies of my arteriogram and stress MRI records. If you are interested in looking at these I would be happy to share them with you.

The letter ends .

Dear Mr Weigel

Yours is an extremely interesting story  told in a most scientific manner.Thank you .

It gives me great insight  ,  how a  human vascular system  can  transform when confronted with  natural disasters like multiple blocks on its way .A flowing river will definitely reach its destination  however bizarre the path it takes . Human biology is vested with vast reserves of genetic building blocks put on sleep  mode. While billions of dollars are being pumped into do research in human angiogenesis we have tuned a  blind eye to the vast net work of natural collaterals.

Our clinical experiences also tell the same thing . In chronic total occlusion  majority of patients would develop good collaterals if only we do not  tamper  the  main vessel  .None of scientific studied available has proven opening CTOs (Chronic total occlusions) has improved the clinical outcome .

Regarding  the guidelines  for revascualrisation ,  I am yet to come across a standard scientific guidelines that includes the extent of collateral circulation  as one of the determinant for need for revascularisation !

I will definitely use your case study for the benefit of so many patients !  I always feel , a properly interpreted experience  , even from a  single patient   can make a tremendous impact in the growth of science .

Thanks again for sharing your personal health issues !

Dr Venkatesan
Chennai .India .

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Coronary collateral circulation is probably the most poorly understood circulation than any other.This  is ignorance at it’s best ,  in spite of the life saving potential  of this circulation. A popular  (mis )perception is  coronary collaterals  can support only  resting blood flow and it would  struggle  to compensate at times of exertion. This is based on few case studies and not based on large , authentic scientific data.

Does this reasoning mean  , coronary  collaterals   can never / ever be complete  ?

If we believe so   . . .we are grossly underestimating the power of  nature .(In fact , mankind  was humiliated by the nature  time and again !)

Lessons  from  a unique patient we have  encountered.

Here is an example of total LAD/LCX  occlusion with good collateral  from  RCA. He was having  stable  angina on medical  management . This patient  was not only  asymptomatic and was also negative for exercise  stress test at moderate work load .

 

 

 

 

 

 

 

 

 

 

 

There was an  intense debate about the management  when this angiogram was presented in the cath meeting .


 

 

 

 

 

 

 

 

 

 

  • Most of the cardiologists believed so !  But they had no answers why his stress test was negative.
  • The other argument for CABG was one can not allow a patient with a functionally single coronary  artery (RCA) However good is the collateral circulation.This at least  has some logic. not the first one !
  • One more suggestion was to quantitate  and map the real extent of ischemia by PET scanning and then decide about revascularisation.
  • One critical opinion was , since he was doing well with medical management what was the need to do coronary  angiogram at all ?

Any answers  . . .

He  ultimately went on to receive CABG (By popular opinion ) , but the point here is the collaterals were  good enough to support exertion.We have  documented quiet a few similar patients with collateral circulation supporting exercise.

What  happened to the collaterals  and (of course ) the patient after surgery ?

I will post you the  curious story soon   . . .

Final message

Coronary  collateral circulation , if well developed  can provide hemo-dynamically useful support even at times of exertion *

* The existing literature  is  biased against this concept. It generalizes all grades of collaterals into a single   entity. It is better  if we  spend more time to understand the nuances of coronary collateral circulation .

This is the  message from our observation. Do not ever believe whatever is published as facts in scientific literature. Observe, analyse , create your own inference ,  and concepts. Mainstream cardiologists would brand it unscientific  , Simply ignore it . Many times it is rewarding  to our patients.

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Chronic total occlusion is the cardiologist’s  daymare .Here is an article that adds on to 1ooth technique to cross the chronic total occlusion within the coronary artery !

If only we succeed in  this  Arabin magic , in the cath lab we can open the doors of  all CTOs .

This technique is based on the principle  to push the hard plaque  into the adjacent side branch like a sliding door,   if the pateint has one !

The only isssue  with this  technique  could be the    “cave door”  may close again immediately  as it did for Alibaba    !

Reference

 http://www.ncbi.nlm.nih.gov/pubmed/20088015

http://www3.interscience.wiley.com/journal/122619470/abstract

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  1. Do 64slice MDCT  in all patients who has  a coronary event and follow it up with catheter based CAG.
  2. Use liberally the new biochemical marker ,  serum  B-naturetic peptide (BNP) to diagnose cardiac failure in lieu of basal auscultation.
  3. Advice  cardiac resynchronisation therapy in all patients  who are in class 4 cardiac failure with a wide qrs complex .
  4. As it is may be considered a  crime to administer empirical  heparin, do ventilation perfusion scan in all cases with suspected pulmonary embolism.
  5. Do serial CPK MB and troponin levels in all patients with well  established  STEMI .
  6. Open up all occluded coronary arteries irrespective  of symptoms and muscle viability.
  7. Consider  ablation of pulmonary veins as an  initial strategy in  patients with recurrent idiopathic AF. If it is not feasible  atleast occlude their left atrial appendage with watch man  device.
  8. Never tell  your patients   the  truths  about the  diet , exercise &  lifestyle modification (That can  cure most of the early hypertension) . Instead encourage the  use of  newest ARBs  or even  try direct renin antoagonists   to treat all those patients in  stage 1 hypertension.
  9. Avoid regular heparin in acute coronary syndromes   as  it  is a disgrace to use it  in today’s world. Replace all prescription of heparin with  enoxaparine  or  still better ,  fondaparinux  whenever  possible.
  10. Finally never discharge  a  heftily  insured patient   until  he completes all the  cardiology investigations  that are available in your hospital  .

Coming soon :  10 more ways to  increase cost of cardiology care . . .beyond common man’s reach

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Annual workshops for interventional cardiologists has been  hugely popular events.They have  become the forum for all technological breakthroughs. Some of the popular ones are

Japanese have gained a unique place in  complex cardiovascular  therapeutics interventions especially in chronic occlusions.

Landmark article for CTO crossing

cto chronic total occlusion  Katoh coronary angiogram

www.cct.gr.jp/2003/wirehand/index.html

www.cct.gr.jp  cto japan

How to reach Japan ?

Click below

CCT2010

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