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Dr. Andrew Rynne

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How can CTO be treated post a failed angioplasty surgery?

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Dr. Ilir Sharka

Cardiologist

Practicing since :2001

Answered : 5712 Questions

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Posted on Fri, 20 Apr 2018 in General Health
Question: Hello, I just had a failed attempt at angioplasty of LCX/CTO. Is there any successful alternatives to tx this or is it just a matter of waiting for a heart attack now as my cardiologist suggests. I do have the classic s/s. Numb jam, shoulder pain etc. although mild. I've lost 72 pounds, don't smoke, exercise and watch what I eat. B/P is fine. After the intervention he just added Imdur and increased Norvasc to 10mg Cholesterol and Triglycerides are fine.Thanks
doctor
Answered by Dr. Ilir Sharka 2 hours later
Brief Answer:
I would explain as follows:

Detailed Answer:
Hello!

Welcome and thank you for asking on HCM!

I passed carefully through your medical history and would like to explain that CTO are in general chronic lesions (more than three months) and they are usually associated with compensatory collateral circulation.

In general they produce symptoms of myocardial ischemia like chest pain; chronic angina, especially if the collateral circulation is not well developed.

CTOs very rarely may be associated with acute coronary syndrome (acute myocardial infarction).

If the symptoms of ischemia (chest pain) persists, percutaneous angioplasty with stent implantation is indicated.

But the rate of success is much lower than a non CTO lesion (up to 70% compared to about 97%).

In such case there are two options:

- First, to optimize an anti-ischemic medication therapy and it seems that your doctor has already done it by the addition of new medications in your treatment.

- Second, if symptoms of chest pain persist again, a new attempt of angioplasty may be a rational strategy.

- Third, if besides LCX/CTO lesion, there exist other coronary lesions, like left main and/or LAD coronary stenosis, etc. a reasonable strategy would be CABG (bypass surgery). In such case it is necessary to confirm that a viable myocardium is present in the area supplied by CTO containing coronary artery.
A cardiac MRI would identify potential viable myocardium in this regard.

You should discuss with your doctor on the above issues.

If you have any other questions, please feel free to ask me again!

Kind regards,

Dr. Iliri
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
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Follow up: Dr. Ilir Sharka 21 hours later
Hello, thanks for the reply. I have angina that happens all the time, even at rest. I believe that the correct term for this is "unstable" angina that is not relieved with Nitrostat. Does this type of angina present any greater risks? I also do aerobic exercise and lift weights. Should I still exercise and just work through the discomfort? Thanks
doctor
Answered by Dr. Ilir Sharka 35 minutes later
Brief Answer:
My opinion as follows:

Detailed Answer:
Hello again!

As you are experiencing chest pain frequently, optimization of medical treatment is very important. But probably it's not enough.

Coronary revascularization strategies I mentioned above should be carefully discusses with your attending cardiologist.

If after a better control of hypertension with anti-hypertensive drugs and your heart rate with a beta-blocker drug, your chest discomfort persists, then a new attempts of coronary angioplasty should be performed.

You should know that physical activity may exacerbate an important cardiac ischemia event, especially in strenuous physical exertion when the coronary collateral system is not well developed.

Coming to this point, I recommend avoiding exaggerated physical training, especially weight lifting and any competitive sports.

Nevertheless, moderate aerobic training may have some beneficial effects regarding stimulation of new collateral vessels within the area supplied by the occluded coronary artery. But, you should avoid continuing exertion while on chest pain.

So, in my opinion, properly modifying your medication strategy and some physical activity are helpful.

But, if symptoms persist again, you need to run for a new revascularization attempt.

Wishing you a pleasant weekend!

Regards,

Dr. Iliri
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Ilir Sharka 48 hours later
SO, I have contacted a specialty Heart and Lung center that specializes in a technique designed for CTO. Apparently they put the catheter between the arterial layers and pop a small curved pin through the upper inner layer that spins and breaks up the clot then they stent it in the usual fashion. Have you herd of this and what is your opinion on it? if this cto was to go only being treated with meds I imagine that the ischemia would eventually get worse resulting in tissue death. Is that a correct assumption?
Anyway, THANKS for all your information!!
doctor
Answered by Dr. Ilir Sharka 5 hours later
Brief Answer:
I would explain:

Detailed Answer:
Hello again!

As you have treated already with percutaneous angioplasty your CTO lesion, then it means that an experienced hand and good luck have met together.

Your CTO has been approached by combining sub-intimal route with usual stenting techniques.

Nevertheless, CTO lesions may be addressed by different techniques (some of them more complex, such as concomitant antegrade and retrograde approach, IVUS utilization, etc.).

I would like to congratulate you!

You shouldn't be afraid of following such a strategy.

It is true that treating CTO lesions may lead to sub-optimal results and a lower rate of success (in experienced and high volume center around 70-80%).

In addition, there are no randomized studies so far to clarify the long term outcomes of these complex treatments.

I think that clinical judgement before the procedure by meeting the most appropriate revascularisation strategy with the least dangerous procedure usually leads to the right therapeutic alternative.

Whether following only a conservative approach (treating only with meds) would lead to myocardial necrosis (tissue death) this could not be concluded with certainty only by a routine clinical analysis. This is a matter of collateral arteries functionality.

This functionality could not by properly investigated by means of only angiographic views. Further physiological tests like FFR would be necessary.

Nevertheless, the fact your CTO lesion has been successfully revascularized doesn't leave space for futile discussions and suspicions on the chosen therapy.

This is the best strategy whenever possible.

Wishing you good health!

Regards,

Dr. Iliri



Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
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