Chronic Total Occlusion

Pembimbing:DR. Dr. Dwi Laksono Adiputro, Sp.JP(K) FIHA

Oleh:Herly Maulida Surdhawati, S.kedI4A011025

BAGIAN/SMF JANTUNGFAKULTAS KEDOKTERAN UNIVERSITAS LAMBUNG MANGKURATRSUD ULIN BANJARMASINJuni, 2015

Chronic Total Occlusion

Definition A complete blockage of a coronaryartery Typically described as >99% stenosed Responsible for clinically significantdecrease in blood flowDefinition Although it is often impossible to know exactly when the occlusion occurred, a CTO is arbitrarily defined as a > 3 month old, total obstruction of a coronary artery. A definition of > 1 month is likely to result in higher reported success rates for a particular treatment strategy.symptomsAngina or chest painPain in the upper body and arms, potentially concentrated on the left sideJaw painIndigestion or choking feelingNauseaDizziness or light-headednessCold sweatRapid or irregular heartbeatUnusual fatigue

CTO lesion.

Non CTO lesion

CTO lesion vs non CTO lesion

Left, A simultaneous angiogram of the left and right coronary systems.

Pinak B. Shah Circulation. 2011;123:1780-1784Copyright American Heart Association, Inc. All rights reserved.Left, A simultaneous angiogram of the left and right coronary systems. The entire length of the chronic total occlusion can be visualized and is outlined in red. Right, The final result after treatment with drug-eluting stents.EKGThere is a suggestion of inferior MI: the T-waves in II, III, and aVF are slightly large. There is T-wave inversion in aVL, which is a soft sign of inferior MI.

Plaque Hard PlaqueFibrocalcific >50%Collagen/Ca++

Soft Plaque>50% Cholesterol MacrophagesLoose Fibrous Tissue

Microscopic section through a chronic total occlusion (CTO) with visible tiny microchannels.

S Aziz, and D R Ramsdale Heart 2005;91:iii42-iii48Copyright BMJ Publishing Group Ltd & British Cardiovascular Society. All rights reserved.Microscopic section through a chronic total occlusion (CTO) with visible tiny microchannels. Courtesy of Dr John Gosney, Royal Liverpool University Hospital, Liverpool.Pathofisiology CTOs consist of various degrees of fibro-atheromatous plaque and thrombus depending on the mechanism of occlusion and its duration. A tough fibrous cap is often present at the proximal and distal margins of the CTO, with softer material in between. Endothelialised microchannels that traverse the occlusion increase the likelihood of passage with low profile hydrophilic guidewires. When the fibrous occlusion is long, densely organised and homogenous, and when microchannels are absent, guidewire passage is less successful and subintimal dissection likely.

Suggested management algorithm for a patient with coronary chronic total occlusion (CTO).

Pinak B. Shah Circulation. 2011;123:1780-1784Copyright American Heart Association, Inc. All rights reserved.Suggested management algorithm for a patient with coronary chronic total occlusion (CTO). CAD indicates coronary artery disease; PCI, percutaneous coronary intervention; CTA, computed tomographic angiography; and CABG, coronary artery bypass graft surgery.

PCI

IVUS (intravascular ultrasound)

Complications The procedural complications include failure to cross with the guidewire or balloon, failure to dilate the lesion, failure to deploy a stent, and myocardial infarction (MI). Coronary artery dissection and/or perforation may lead to haemopericardium, cardiac tamponade, and death unless prompt pericardiocentesis and reversal of anticoagulation halts the demise. Emergency CABG surgery may be necessary.cabg

conclusionImproved technique, specialised guidewires, and stenting have improved the success rates of PCI in CTOs, but innovations are required to deal with the more difficult subset of CTOs such as old, long, and calcified lesions with unfavourable anatomy. The novel devices described above now need to be formally tested to assess their true worth.

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