Our CTO (Chronic Total Occlusion) service in Bath

We are proud of our mature CTO (chronic total occlusion) service in Bath and it is important that we start to publicise the good work that’s going on. The success of the programme is due to a combination of an excellent team and access to the full compliment of modern technology and interventional devices. This allow us to deliver an advanced service to patients in Bath and the surrounding areas. Traditionally for many of these patients, who continue to have symptoms despite optimal medical therapies, the only remaining options would have been to accept the limitations of the condition or open-heart surgery. Many would have been told that angioplasty was not possible.

The pathway is driven by a multidisciplinary approach which optimises patient selection and preparation through advanced imaging assessment (usually cardiac MRI). Patients can expect the procedures to be performed under local anaethesia with sedation for comfort. The usual approach will involve access through the wrist as well as the groin so that the occlusion can be progressed from both sides (sometimes instead of the wrist both sides of the groin will be accessed).

The blockage can be penetrated at the front end (antegrade) or via collateral supplying vessels that lead to the back end (retrograde). In some circumstances passage through the occlusion is not possible or efficient and in these case the wires or devices are navigated around the blockage within the wall of the artery. If the blockage is very hard (calcified) then drills (rotablation) or laser can be used to facilitate the delivery of stents. A successful programme is dependent on access and expertise with all these techniques and equipment.

The case above is a good example of the type of work that is currently being undertaken. This patient had troubling angina despite good medical therapy and a long-term occlusion of the right coronary artery which had been considered unnameable to angioplasty in the past.

The approach was via the right wrist and right groin. Initially the occlusion was interrogated from the front (antegrade) but because of course ambiguity and multiple small vessels at the point of occlusion it was clear that the chances of successfully navigating in the correct direction were limited. The strategy was switched to a 'retrograde' approach with the aim of reaching and traversing the occlusion from the back.

The usual retrograde approach would be to access collaterals from the left sided arterial system but these were underdeveloped without a good 'interventional collateral option'. The remaining option was to use an antegrade dissection re-entry technique (bypass the blockage by penetrating and passing in the wall of the artery) but in this case there was a possible ipsilateral collateral.

By navigating through the ipsilateral collateral the occlusion was penetrated and crossed from the back (retrograde) and this then allowed the passage of balloons and stents to reconstruct the artery. The final image shows the result and the patient was discharged the following morning.