Treatment of chronic total occlusions (CTO)

By Dr. Seyed Mohsen Jahromi-Moghadam in the most advanced hospitals in Mashhad

What is a chronic total occlusion (CTO)?

CTO, or Chronic Total Occlusion, is a condition in which one of the coronary arteries of the heart has been completely, 100%, blocked for more than 3 months.

In this situation, the normal pathway of blood flow to the heart muscle is interrupted, and the heart uses collateral vessels to compensate, which are usually not sufficient.

✅ These types of blockages are considered among the most complex lesions in coronary angioplasty, and their treatment requires extensive experience, specialized skill, and advanced equipment.

Common symptoms of CTO

Many patients with CTO present with the following symptoms:

• Chronic or exertional chest pain
• Shortness of breath, especially during activity
• Early fatigue
• Reduced functional capacity of the heart
• Sometimes no symptoms, but reduced EF or ischemia on tests

How is CTO diagnosed?

The definitive diagnosis of CTO is made through coronary angiography.

Angiography shows that:

• The vessel is completely blocked
• The blockage has been present for a long time
• The natural course of the vessel is not visible
• Collateral vessels have become active to supply the affected area

After angiography, the patient is evaluated by an interventional vascular subspecialist, and the best treatment method is selected.

Does CTO always require open-heart surgery?

❌ No

Unlike in the past, today many cases of CTO can be treated without open-heart surgery, using only advanced angioplasty (CTO PCI).

✅ These procedures should only be performed by physicians who have received specialized CTO training.

Methods for opening chronic total occlusions (CTO PCI)

Opening a CTO requires advanced techniques and special tools, selected according to the vessel anatomy:

1️⃣ Antegrade approach, moving through the natural vessel pathway
 

• Passing very fine, specialized wires through the occlusion
• Suitable for simpler CTO lesions

2️⃣ Retrograde approach, moving through collateral vessels

• Entering the occluded vessel through collateral vessels
• Used for complex and long-standing CTO lesions

3️⃣ Dissection & re-entry techniques

• Creating a controlled pathway in the vessel wall
• Re-entering the main blood supply channel

4️⃣ Use of advanced equipment

• Specialized CTO wires
• Microcatheters
• Special balloons
• If needed, rotational atherectomy (ROTA) for severely calcified plaques

Finally, after successful crossing, angioplasty and stent placement are performed.

Benefits of successful CTO treatment

✔ Reduced chest pain

✔ Improved shortness of breath

✔ Increased heart function and EF

✔ Improved quality of life

✔ Reduced need for open-heart surgery

✔ Reduced use of antianginal medications

CTO treatment by Dr. Seyed Mohsen Jahromi-Moghadam

Treatment of chronic total occlusions (CTO) is performed by Dr. Seyed Mohsen Jahromi-Moghadam

Interventional vascular and endovascular fellowship-trained specialist.

🔹 CTO angioplasty using the latest techniques worldwide

🔹 Use of advanced CTO and ROTA equipment

🔹 Procedures performed in the most advanced hospitals in Mashhad

🔹 Precise patient and treatment-method selection based on anatomy and cardiac condition

✅ Initial evaluation and patient follow-up are performed at Delban Clinic in Mashhad.

Which patients are candidates for CTO opening?

The final decision for CTO treatment is based on the following:

• Patient symptoms
• Extent of ischemia
• Heart muscle function
• Vessel anatomy on angiography
• Patient's general condition

📌 Treatment selection is fully specialized and patient-centered.

Summary

Chronic total occlusion (CTO) is one of the most complex coronary artery diseases, but today it can be treated with advanced angioplasty and without open-heart surgery,

provided it is performed by a physician with specialized CTO skill and experience in well-equipped centers.