New approaches to coronary occlusion

Patients who experience chest pain or shortness of breath will often find that coronary artery disease is the cause of their symptoms.

Coronary artery disease is one of the top causes of death in the UK and worldwide. It is a result of the build up of fatty substances within the coronary arteries, causing blockages and the arteries to become narrow and rigid. This restricts blood flow to the heart and the supply of oxygen and nutrients, which has a direct effect on the heart’s function.

Percutaneous coronary interventions such as coronary angioplasty or stenting are not always possible in complex cases of coronary artery disease and can sometimes leave patients with residual blockages if they have multiple stenoses. Recent studies show that it is advantageous to reopen all arteries that show significant lack of blood flow. 

Arteries that have been blocked for 30 days or more, called chronic total occlusion, have been difficult to clear in the past, and the only options were coronary bypass surgery or medical therapy.

However, newer interventional techniques have significantly improved the chances to open such blocked arteries without surgery, and to achieve complete revascularisation.

Antegrade wire escalation approach

In this new approach, guidewires have been specifically designed to penetrate the blockages in the arteries. These stiff coronary wires penetrate the occlusion and negotiate through the blockage. Specific guidewires have been developed which are much more precise, which can penetrate such blockages much better and more safely. This is called the 'antegrade wire escalation approach'. Over recent months, a multitude of new wires and assisting devices have been developed. 

Retrograde approach

We can now also 'attack' such challenging blockages from the usually softer backside, instead of the very calcified hard front side. This is called the 'retrograde approach'. We have techniques that allow us to advance our wire via tiny, almost invisible, natural bypass arteries (collateral arteries) to the back side of the occluded vessel and then open it from there.

Dissection re-entry approach

A novel technique is the so-called 'dissection re-entry approach' where we bypass the blockages which are hard to pass by a controlled dissection and then re-enter into the true lumen further down. This technique is rather revolutionary and has increased our chances to open complex blockages. 

Patients with chronic occlusions that have progressed slowly do not always exhibit typical symptoms such as tightness in the chest but will experience breathlessness. They often react to this breathlessness by adjusting their lifestyle and becoming less physically active. Only through opening all relevant blockages will the patients quality of life improve as symptoms decrease.

For the initial diagnosis in a patient with suspected coronary artery disease, it is generally recommended that a non-invasive test such as a stress echocardiogram is performed. However, if the patient exhibits typical symptoms, it is often preferable to directly perform a coronary angiogram.

Prior to any treatment decision, two factors must be taken into consideration: which coronary blockages are primarily responsible for the patient’s symptoms and whether the heart muscle is still viable. It is important to select patients carefully to ensure maximum benefit from these procedures.

An alternative and well-established treatment option is coronary artery bypass graft (CABG) surgery. However, this is major surgery and not always possible.

Each patient case is discussed by a team of experts at the RB&HH heart team meeting in order to come up with the optimal treatment plan for each individual.

At a glance

Procedures

Antegrade wire escalation approach, retrograde approach, dissection re-entry approach

Carried out by

Dr Ranil de Silva, consultant interventional cardiologist

What problem does it solve?

This offers multiple non-surgical approaches to complex coronary artery disease

Who would benefit from these options?

People with angina (exercise-induced chest pain) or shortness of breath where we find a completely blocked coronary artery as the underlying cause.