Interventional Cardiologist

CTO & CHIP Operator

Specializing in Complex Coronary Interventional procedures with excellent success rates

Dr. Anand Gnanaraj is a highly skilled Interventional Cardiologist with over a decade of experience with expertise in CTO (100% blocks) and CHIP (Complex PCI)

A long standing (more than 3 months), 100% blocked coronary artery is called a CTO (Chronic Total Occlusion). CTOs can develop after an untreated or incompletely treated heart attack that leads to a 100% blocked artery or can develop gradually over a period of years. This slow process provides an opportunity for the heart to develop collaterals (small channels that connect the blocked segment to the other arteries of the heart that have good blood flow). These collaterals can keep the heart muscle alive and functioning almost normally at rest. The best of collaterals can provide about 10–15% of the blood flow needed by the heart muscle in the blocked area. This translates to an 85–90% block.

Though there is a school of thought that believes that arteries with collaterals need not be treated, most of these patients clearly benefit from angioplasty. if you look at their symptoms closely, 90% of these patients have chest discomfort or breathlessness during exertion. Most of these patients have gradually adjusted their life style to avoid the symptoms. Invariably, when questioned skillfully, patients realize that they have been having symptoms. A more scientific way of dealing with this is to do a myocardial perfusion study. This is a study that can objectively tell you if the heart muscle is starved of its blood supply or not. It can show either reversible ischaemia or good viable heart muscle in the blocked artery’s territory.

If the patient has absolutely no symptoms, if the perfusion studies show no ischaemia and if the CTO is in a small artery, not supplying significant heart muscle (myocardium), then an angioplasty may not be indicated. In most cases, patients who come to the hospital for a cardiac problem are usually symptomatic and have a major artery blocked which supplies a large area of heart muscle. These patients definitely benefit from the procedure, both symptomatically and prognostically.

Managing CTO Cases

Dr. Gnanaraj has conducted 6 international workshops at the Apollo Speciality Hospital, Vanagaram where Japanese faculty have come and demonstrated CTO procedures. He conducts regular training programs for cardiologists around the country on CTO interventions, using the latest technologies and imaging modalities like Intravascular Ultrasound (IVUS) and Optical Coherence Tomography (OCT). He also travels to various hospitals in the country to demonstrate and perform complex CTO procedures

Interventional Cardiology

There is a major downside to the traditional view of medical management. The reason why anyone develops a CTO is because he or she has atherosclerotic obstructive coronary artery disease. Now, this 100% blocked major artery is supplied by collaterals (inadequately) through another major artery of the heart. It is to be remembered that the patient is NOT free of the primary problem (atherosclerotic coronary artery disease) and the disease usually continues to progress in spite of medical treatment. If this patient has an Acute Coronary Event (A heart attack - which is a sudden occlusion of a coronary artery) involving the artery that supplies the collaterals, there is complete loss of blood flow in 2 major arteries. This usually leads to death in minutes and does not give the patient an opportunity to reach hospital. This is the most important reason for performing an angioplasty on a CTO.

Almost all patients report an immediate feeling of wellbeing after the CTO angioplasty and long term relief from symptoms. Doing a CTO angioplasty does not close the collaterals. The collaterals become non functional, but anatomically present and can open up spontaneously if needed at a later date.

The risk of a CTO procedure to open a 100% blocked artery is minimally more than a regular angioplasty (0.5%), but still less than the risk of a Bypass surgery. In todays world, the risk of dying from the 100% block is more than the risk of the procedure itself. So, it is definitely warranted.

Dr. Gnanaraj performed Angioplasty my father with 100% block when the only option given to me was bypass surgery.

I am forever grateful for his expertise and care.

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