We all know. If a stone obstructs a water pipe, the flow is blocked and immediate action must be taken to avoid problems. But there are also cases in which deposits in the duct are created progressively, up to leading to the same result, but giving signs over time. Something similar can also happen to the coronary arteries, those that supply the heart. If a plaque breaks and suddenly becomes obstructed, a heart attack can appear, resulting in a rush to the hospital and, if possible, treatment with angioplasty (the balloon that dilates the vessel and any mesh, the stent, which keeps dilated). But what should be done if the coronary is completely occluded over time, that is, the CTO, English acronym for chronic total occlusion? Experts are finding new ways to tackle this very serious condition, as emerged from the EuroCTO Club congress, held in Florence.
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“Heart attack is an acute event, with the classic symptoms that require immediate treatment because time is of the essence – he explains Carlo Di Mario, Professor of Cardiology at the University of Florence and Director of Structural Cardiology Intervention at the Careggi Hospital as well as President of the EuroCTO Club – however, when the occlusion occurs slowly, over the course of weeks or months, the event is less dramatic with symptoms more nuanced and sometimes insidious and difficult to grasp. There is time for collateral circles to form, a network of small arterioles that go from an open coronary to one that is closing, guaranteeing enough blood not to induce a heart attack, the death of a part of the heart muscle “.
However, this situation leads to a reduction in the function of part of the heart, enormously increases the risk of death if the artery from which the network of collaterals derives becomes ill, often associated with disabling symptoms. Reopening an artery when the occlusion has been present for months or years and the occluded segment has become fibrotic or calcified is very difficult. “It is often necessary to use two tubes (catheters) inserted from the wrist or from the groin that inject an opaque liquid to X-rays (contrast medium) in both coronary arteries so it is understood in which direction the rigid guide wires developed specifically for this purpose must be moved and can be finely adjusted by turning them from the outside – resumes the expert. Sometimes this approach is not enough and it is necessary to use different guide wires, so flexible and non-traumatic as to follow the network of collateral vessels from the healthy artery to the occluded one, using what is called retrograde technique ”.
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Obviously the treatment to choose must be evaluated case by case. But it is certain that this approach can have several advantages for the patient who has chronically occluded coronaries. “With sufficient experience and with modern materials and techniques, 80-90% of total occlusions can be opened with catheterization, thus avoiding the need for the patient to undergo a much more invasive procedure such as coronary artery bypass grafting, which it requires the opening of the sternum and the arrest of the heart, with weeks of hospitalization in hospital and then in a rehabilitation center for slow recovery – says the expert ”. If you are able to open the occluded artery with angioplasty, the classic surgery is not necessary, the patient must not be asleep or intubated because he does not feel bad during the procedure, and can go home the day after the angioplasty. During the Florence congress, with live clinical cases, it was seen that patients have been successfully treated, reopening an artery closed for years, often after a failed angioplasty by less experienced operators using less innovative techniques and materials.
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However, the important thing is to be able to recognize who has coronary arteries that have slowly become encrusted and then closed. And it’s not always easy. “Symptoms can be insidious and patients with total occlusion more often have shortness of breath under exertion than classic angina, the typical retrosternal pain caused by lack of blood to the heart muscle – says Di Mario. Given also the gradual worsening, patients often attribute the symptoms to different problems, for example respiratory problems, or adapt to reduce their physical activity considering the easy fatigue an inevitable consequence of advanced age or lack of adequate training. Often the problem is noticed only on the basis of an electrocardiogram, an echocardiogram or an altered exercise test, performed for other reasons ”.
And then … then we proceed with a coronary angioTAC which is very sensitive in showing coronary narrowing and is able to identify the location and length of the occlusion in a non-invasive way, also helping the planning of the reopening procedure with angioplasty of the chronic coronary occlusion. “By reopening the occluded arteries we have incontrovertible evidence, even in randomized studies, that dyspnea and angina improve and patients are able to make efforts that were not tolerated before. – concludes the expert. The clinical studies conducted so far, however, are not large enough and of a sufficiently long duration to prove incontrovertibly that reopening a chronic coronary occlusion also improves mortality “.
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