CTO: Blocked Artery, Antalya | Prof. Dr. Umuttan Doğan

A completely blocked artery means a coronary artery that is not partly narrowed but closed altogether. When the blockage has been there for three months or longer, it is called a chronic total occlusion (CTO). In the past a good proportion of these arteries could not be treated by catheter. Today, with specialised guide wires, microcatheters and advanced techniques, arteries that have been shut for months or even years can be opened again. Not every blocked artery needs opening, though; the decision follows a careful assessment.

What Is a Chronic Total Occlusion?

Coronary artery disease usually begins with a narrowing. The plaque grows over time and at some point closes the artery completely. Blood can no longer pass through it.

CTO stands for chronic total occlusion.

What is inside the blockage changes over time. What begins as soft clot in the first days hardens over the months, with fibrous tissue and calcium building up inside it. That is the main reason the procedure is demanding.

How Long Is “Chronic”?

The accepted limit is three months. An artery that has been completely closed for longer than that is regarded as chronic.

In practice it is not always possible to know exactly when the blockage formed. A heart attack in the past, an older angiogram recording or the point at which the symptoms began all help to place it.

How Is a Blocked Artery Noticed?

Symptoms differ markedly from person to person:

Chest pain or a feeling of pressure when walking, going uphill or on exertion
Tiring easily, finding things hard that used to be comfortable
Breathlessness
In some people, no symptoms at all

That last point may come as a surprise. The reason is in the next section.

How Is a Completely Blocked Artery Diagnosed?

A blockage is not established by one test. The usual path is a stepped one.

Examination and history: when your symptoms began, at what level of effort they appear and how long they last are the first things to know. A history of heart attack matters.
ECG: it can show the traces of an old heart attack. A normal ECG does not mean there is no blockage.
Echocardiography: it shows how the heart muscle contracts. Reduced movement in the area the blocked artery supplies can stand out.
Exercise testing or a myocardial perfusion scan: these show which area is not being supplied well enough during exertion.
CT coronary angiography: it can show where the blockage is, how long it is and how calcified, without going inside. It is useful at the planning stage.
Coronary angiography: this is what establishes the diagnosis. The point where the blockage begins, its length and the pattern of the collateral vessels are seen here.

A blocked artery is often found unexpectedly, during an angiogram done for another reason. When that happens the decision is not rushed; the assessment is completed first.

How Does the Heart Keep Working with an Artery Completely Blocked?

This is what patients most want to know and what is explained least.

If an artery closes gradually rather than suddenly, the body does not stand still. Fine side routes develop from neighbouring arteries towards the blocked area. These are called collateral vessels — in everyday terms, the natural bypasses the heart builds for itself.

Collaterals can keep the heart muscle alive. But their capacity is usually limited. Flow that is enough at rest may not meet the demand during exertion. That is why chest pain so often appears while walking and settles with rest.

So “my artery is blocked but I am fine” is an incomplete assessment. The real question is whether that area is being supplied well enough under exertion.

Should Every Blocked Artery Be Opened?

No. A blockage on its own is not a reason to operate. The decision takes in:

Your symptoms. Despite medication, is there still chest pain, breathlessness or a limit on what you can do?
The size of the area supplied. If the blocked artery feeds a large part of the heart, the procedure means more.
Is the muscle alive? If that area was damaged completely in the past and has turned to scar tissue, opening the artery brings the muscle no benefit.
The state of the other arteries. Where there are narrowings elsewhere, the treatment plan is built as a whole.
The pumping strength of your heart and your general health.

How Do You Tell Whether the Muscle Is Still Alive?

The answer to this decides the procedure. The methods that can be used include a myocardial perfusion scan, stress echocardiography and cardiac MRI.

The aim is to answer one question: is the muscle supplied by the blocked artery still alive, and able to recover if the blood flow improves? If the answer is no, the procedure will not deliver the expected benefit and is not pursued.

What Can Be Expected from the Procedure?

Setting the expectation correctly matters as much as the decision itself.

In suitable patients, the main aim of a CTO procedure is to reduce symptoms: less chest pain on exertion, walking more comfortably, managing daily tasks without struggling. Some improvement in the pumping strength of the heart may also be seen.

Alongside that, a few points should be said plainly:

The procedure does not do away with the artery disease. The process in the other arteries carries on.
Medication continues after the procedure. If a stent has been placed, blood thinners are taken for the period set out.
Results differ from person to person. How much the symptoms ease depends on the area the blocked artery supplies and on whether that muscle is alive.
If much of the muscle has turned to scar after an old heart attack, opening the artery will not bring that area’s contraction back.

The benefit you can expect is therefore discussed openly beforehand. Where that benefit is limited, the procedure is not recommended.

How Is a CTO Procedure Carried Out?

Opening a completely blocked artery is longer and more detailed work than a standard coronary procedure. It is still not surgery: it is done under local anaesthetic, entering at the wrist or the groin.

Much of the time the work is done from two sides at once. One catheter images the blocked artery, the other the neighbouring artery that feeds the collaterals. That way both the start and the end of the blockage can be seen at the same moment. This is called dual injection, and it makes finding the way easier.

The Antegrade Approach

Here the work follows the normal direction of blood flow. Specialised guide wires are used to try to cross from the point where the blockage begins. Wires differ in stiffness and in the shape of their tips; as the resistance increases, a more suitable wire is used. A microcatheter supports the wire and steers it.

This is the first choice in most procedures.

The Retrograde Approach

If the antegrade route does not succeed, or the entry point of the blockage is unsuitable, the work goes the other way round. The collateral routes coming off the neighbouring artery are used to reach the blockage from behind.

This is an advanced technique and requires the collaterals to be suitable for it. It is not possible in every patient.

The Part Imaging Plays

Once the blockage has been crossed, the true diameter of the artery and the structure of its wall need to be known. IVUS (intravascular ultrasound) is used at this point: it shows whether the wire is travelling in the right layer, what size the stent should be, and whether it has opened fully at the end.

Where there is heavy calcium within or around the blockage, the artery may need preparing before the stent. Treatment for calcified arteries comes into play at this stage.

How Do You Prepare?

Your earlier records: if you have older angiogram images, bring them on a disc or as a digital file. How the blockage looked before has a direct bearing on the planning.
Your viability tests: keep your perfusion scan, stress echocardiography or cardiac MRI reports with you.
Your list of medicines: write down everything you take, with the doses. Blood thinners and diabetes medicines matter particularly.
Your kidney results: CTO procedures may use more contrast dye than a standard angiogram. Your kidney function is assessed beforehand.
Any history of allergy: tell the team if you have reacted to contrast dye or to a medicine before.

Before the procedure you are told what will be done, what benefit is expected and what the possible risks are, and your written consent is taken.

What Will You Feel, and How Long Does It Take?

You are awake throughout. Local anaesthetic is given at the access site; you will not feel the wires and catheters moving inside the artery.

There may be brief chest discomfort while a balloon is inflated, passing once it is let down. Lying in the same position for a long time can be tiring. It is important to tell the team whenever you are uncomfortable.

It would not be right to give a firm figure for the time. CTO procedures take markedly longer than a standard angioplasty; it depends on the length of the blockage, the calcium, how much the artery bends and which technique is needed. You will be told what to expect in your own case.

CTO, Bypass or Medication?

All three are on the table, and none is automatically the alternative to another.

Medical treatment: where there are no symptoms, or they are controlled with medicines, managing the risk factors and regular follow-up may be right on their own.
Opening by catheter (a CTO procedure): considered where symptoms persist despite medication, a large area of living muscle is involved and the anatomy of the artery is suitable.
Bypass surgery: considered where disease is widespread in more than one artery, the left main coronary artery is involved, or the anatomy is unsuitable for a catheter approach.

In complicated cases the decision is not made by one doctor but through a process in which cardiology and cardiac surgery give their views together. Your own preference is part of that process.

What Are the Possible Risks?

A CTO procedure is longer and technically more demanding than a standard stent procedure. Knowing that lets you ask the right questions.

Bruising, bleeding or swelling at the access site
Temporary effects on kidney function from the larger amount of contrast dye
Injury to the wall of the artery; rarely a tear, and fluid collecting in the sac around the heart
More radiation exposure in long procedures
Changes in rhythm during the procedure
Narrowing developing again later where the stent was placed

These are discussed in detail for your own situation at the consultation beforehand. The benefit you can expect is weighed against the risk it carries; where the balance does not favour the benefit, the procedure is not recommended.

Afterwards

The access site is watched for a period; where the wrist was used, getting up is usually earlier.
If a stent was placed, blood-thinning medicines are taken regularly for the period your doctor sets. Do not stop them on your own.
Cholesterol, blood pressure and blood sugar continue to be managed. The process that causes artery disease does not end with the procedure.
Smoking is stopped.
Activity is increased in stages; a cardiac rehabilitation programme may be recommended.
Cardiology review is carried out at set intervals.

If you notice a change such as chest pain, breathlessness or swelling at the access site, see your doctor without waiting.

Treatment for a Completely Blocked Artery in Antalya

Prof. Dr. Umuttan Doğan is a cardiologist working in complex coronary artery procedures. CTO procedures are carried out in the catheter laboratory at Antalya American Hospital.

If you have had an angiogram and been told that one of your arteries is completely blocked, you can be seen at the clinic in Konyaaltı with your images, your viability tests and your symptoms. You will find his background and contact details on their own pages.

Frequently Asked Questions

Can an artery that has been blocked for years really be opened?

How long the blockage has been there is not decisive on its own. Arteries shut for months, even years, can be opened with specialised wires and microcatheters. The outcome depends on the make-up of the blockage, its length, how calcified it is and the anatomy of the artery. Each artery is therefore assessed on its own.

My artery is blocked but I have no symptoms. Should it still be opened?

Having no symptoms may have to do with the collateral routes from neighbouring arteries being enough at rest. The decision is not made on symptoms alone; the size of the area the blocked artery supplies, whether the muscle there is alive and how things stand under exertion are all considered together.

Does a CTO procedure take the place of bypass surgery?

They are different methods and neither is automatically the alternative to the other. Where a single artery is blocked, opening it by catheter may be considered. Where there is widespread disease in several arteries or the left main coronary artery is involved, bypass is considered. The decision takes the anatomy of your arteries and your general condition together.

What happens if the procedure does not succeed?

It is not always possible to cross the blockage. If that happens the procedure is brought to an end and the options are looked at again: a second attempt with a different technique may be planned for later, bypass may come onto the table, or treatment may continue with medicines. This possibility is discussed with you beforehand.

Why does a CTO procedure take longer than an ordinary angiogram?

The inside of the blockage hardens over time, with fibrous tissue and calcium building up. Getting the wire through that in the right layer takes time. In most procedures two arteries are imaged at once, and the technique is changed when it needs to be. CTO procedures therefore take markedly longer than a standard angioplasty.

The information on this page is for general guidance and does not replace a consultation. Decisions about diagnosis and treatment are made by your doctor after assessing your own situation.