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Chronic Total Occlusion – Conquering the Last Frontier in Coronary Intervention

(L to R) Nelson Bernardo, MD, and Robert Gallino, MD

Despite dramatic improvement in outcomes over the past decade, the percentage of Chronic Total Occlusions (CTOs) treated by percutaneous coronary intervention (PCI) remains stubbornly low nationwide, at about 5 percent. But Nelson Bernardo, MD, and Robert Gallino, MD, both experienced masters of the intricate and demanding technique at MedStar Heart & Vascular Institute, want to change those statistics—and help more patients with CTO feel better and live longer, without open heart surgery.

One part of their strategy is correcting out-of-date, but still lingering misperceptions among the medical community about the safety and effectiveness of PCI for CTO. The other is training select interventional cardiologists in the procedure's subtleties to expand the numbers of skilled operators and make the benefits of CTO PCI more widely available.

“In the past, the ability to treat CTO successfully with PCI was pretty low, only about 70 percent, with a significant risk of cardiac perforation and other complications,” says Dr. Bernardo, medical director of the Peripheral Vascular Laboratory and co-chair for cardiac peripheral vascular disease.

“But today, high volume centers like ours typically report success rates for CTO PCI of around 90 percent. Actually, in 2017, we performed 53 CTO PCIs and totally opened up the occlusion in all but one of the patients. That translates into a success rate of 98 percent.”

Such progress is the result of continuing innovations that now allow interventional cardiologists to treat a disease that was once only amenable to open heart surgery. Chief among them are the development and improvement of specialized tools, with dedicated guidewires, microcatheters, and other supportive devices, making even the most complex lesions and anatomies easier and safer to navigate and cross. The advent of drugeluting coronary stents further enhanced outcomes, by improving long-term patency of the revascularized vessel.

But as in so many complex procedures, the key determinant to an optimal outcome is the individual operator’s experience and skills, based upon volume. A sophisticated infrastructure with an accomplished cardiac catheterization lab is also a necessity.

Since launching the program in 2015, MedStar Washington Hospital Center has emerged as one of only a very few hospitals in the U.S. termed high-volume CTO PCI centers—those doing 50 or more of the procedures each year. To date, Drs. Bernardo and Gallino have performed 174 CTO PCIs.

CTOs can affect one or all of the coronary arteries and are a fairly frequent occurrence. In fact, out of every 100 patients undergoing non-urgent coronary angiography, around 20 will be diagnosed with CTO.

“Unfortunately, many cardiologists still believe CTOs cannot be opened, or that opening the CTO will not lead to a significant clinical improvement,” says Dr. Gallino. “Yet our personal experience, particularly with PCI, continues to illustrate the benefits of opening a total occlusion, even those that have been closed for 10 years or longer.”

Recent studies corroborate their observations. One clinical trial demonstrated that using PCI to open totally blocked coronary arteries can offer symptomatic relief for patients with angina, helping them feel better [https:// www.tctmd.com/news/eurocto-revascularization-bestsmedical-therapy-quality-life-cto-lesions]. Two other clinical trials also showed a marked improvement in the quality of life for patients post-CTO PCI related to relief of lifestylelimiting fatigue and shortness of breath [Am J Cardiol. 2013;111(4):521-5 and J Am Coll Cardiol. 2014;64(3):235-43].

A successful PCI depends upon thorough evaluation and pre-planning to examine each potential candidate’s individual coronary anatomy and morphology. Factors include lesion length, the size and location of the distal target vessel, the existence of significant bifurcation, and the anomalies of the collateral vessels, including size and tortuosity. The specialist then devises the best strategy for achieving complete revascularization using the antegrade or retrograde approach, along with a series of back-up plans to address unforeseen difficulties that may arise.

Once the plan is in place, the procedure gets underway. While CTO PCI is more difficult for physicians—the American College of Cardiology still called it “highly challenging” as recently as 2015—it is fairly straightforward for patients.

(Left image, L to R) Robert Gallino, MD, and Nelson Bernardo, MD, perform a revascularization of complex chronic coronary total
occlusion (CTO).

“After we perform CTO PCI, the patient is usually able to go home the next day and can resume regular activities a few days later,” says Dr. Gallino. “By contrast, patients who have had open heart surgery typically spend between seven and 10 days in the hospital, followed by six weeks of recovery.” CTO PCI is still relatively new, but Drs. Bernardo and Gallino believe the outlook for the procedure is promising.

“In those cases where only one artery is totally occluded, we already know it’s simply not worth the risk to perform open heart

surgery when a minimally invasive PCI may be able to fix the problem,” Dr. Bernardo says. “Theoretically, PCI can help the CTO patient live longer, as well, by potentially avoiding a myocardial infarction or contributing to an improved left ventricular function. If on-going and future studies continue to show significant positive impact on health and mortality, PCI could clearly change the treatment arc for coronary CTOs in the future.”

Until that day, both doctors are happy with what PCI can offer patients now. “The improvement in the patient’s lifestyle is the most rewarding aspect of why we do the procedure,” concludes Dr. Gallino.

SPREADING THE WORD… AND THE SKILLS

As leading specialists in percutaneous coronary intervention for CTOs, Drs. Nelson Bernardo and Robert Gallino are sharing their knowledge and experience with select cardiac interventionalists to raise awareness of the procedure and train others.

They have been working since 2014 to develop an animal model to represent the condition and its vagaries. Using a pig model to replicate CTO in a human, they offered their first day-long course earlier this year to train practitioners in the art and skill of crossing CTOs.

“We want to provide a venue for interventional cardiologists to hone their expertise in CTO PCI,” explains Dr. Bernardo. “This model could also serve as a testing platform for guidewires and devices developed to cross CTOs as well as for evaluating different therapeutic options.”

To schedule a consultation with Drs. Bernardo or Gallino, call 202-877-5975.