Recanalization of chronic total coronary occlusions: the impact of a new specific guidewire on primary success rate

BACKGROUND: Although chronic total occlusions are encountered frequently in patients with coronary artery disease, an effective strategy to deal with them has yet to be devised. Various new guidewires have been designed in an attempt to negotiate chronic occlusions successfully. The authors have analysed the impact of the Athlete guidewire on procedural success in this lesion subset. METHODS: Sixty-two consecutive patients undergoing percutaneous intervention for chronic total occlusions over a twoyear period were retrospectively studied. For the initial attempt, conventional guidewires were used. In case of failure, further attempts were made using the Athlete guidewire. Procedural success rates with the use of conventional and Athlete guidewires were assessed. RESULTS: Failure of the first attempt with the conventional guidewire occurred in 32 (51.6%) patients and success was achieved in 30 (48.4%) patients. In the former patients, a second attempt was made using the Athlete guidewire to cross the occlusion. The second attempt was successful in 20 patients (60%) in whom the first attempt was unsuccessful, while in the remaining 12 (40%) patients the occlusion could not be crossed even during the second attempt and the procedure was then terminated. Following the use of the Athlete guidewire, the success rate increased to 62% ( p < 0.001). No complication occurred during the first attempt, while one patient had a coronary perforation using the Athlete guidewire, which was managed successfully without the need for bypass surgery. CONCLUSION: The use of the Athlete guidewire is feasible and safe, and enhances the chances of successfully treating chronic total occlusions during percutaneous coronary revascularization procedures. (Int J Cardiovasc Intervent 2000; 3: 105-110)     

Immediate and mid-term outcomes of sirolimus-eluting stent implantation for chronic total occlusions.

AIMS: To evaluate the outcomes of sirolimus-eluting stent (SES) implantation for the treatment of chronic total occlusion (CTO). METHODS AND RESULTS: We identified 122 patients who underwent revascularization in CTO lesions with SES from April 2002 to April 2004 (SES group). A control group was composed of 259 consecutive patients with CTO lesions treated with bare metal stents (BMS) in the 24 months immediately before the introduction of SES (BMS group). At 6-month follow-up, the cumulative rate of major adverse cardiac events (MACE) was 16.4% in the SES group and 35.1% in the BMS group (P<0.001). The incidence of restenosis was 9.2% in the SES group and 33.3% in the BMS group (P<0.001). The need for revascularization in the SES group was significantly lower, both target lesion revascularization (7.4 vs. 26.3%, P<0.001) and target vessel revascularization (9.0 vs. 29.0%, P<0.001). BMS implantation (HR: 2.97; 95% CI: 1.80-4.89; P<0.001), lesion length (>20 mm) (HR: 2.02; 95% CI: 1.37-2.99; P=0.0004), and baseline reference vessel diameter (>2.8 mm) (HR: 0.62; 95% CI: 0.42-0.92; P=0.02) were identified as predictors of MACE during 6-month follow-up. CONCLUSION: Compared with BMS, SES implantation in CTO lesions appears to be effective in reducing the incidence of restenosis and the need for revascularization at 6 months.     

介入治疗开通慢性完全闭塞病变的长期临床疗效

目的 评价经皮冠状动脉介入治疗(PCI)成功开通冠状动脉慢性完全闭塞(CTO)病变对长期临床疗效的影响.方法 对1993年6月至2006年12月连续1332例冠状动脉CTO住院患者的临床资料进行分析.根据PCI结果将患者分为成功组(n=1202)和失败组(n=130),对比两组患者长期生存率、无主要不良心血管事件生存率及接受冠状动脉旁路移植术(CABG)的差别.结果 总病例成功率为90.2%(1202/1332),成功组患者PCI后10年生存率、无主要不良心血管事件生存率均明显高于失败组(分别为76.9%比64.6%,log rank P=0.012;41.8%比27.6%,log rank P<0.001),接受CABG患者则显著少于失败组(4.3%比14.6%,P<0.001).结论 PCI开通CTO病变可明显提高患者长期生存率和无主要不良心脏事件生存率,并减少对CABG的需求.     

65例冠状动脉慢性闭塞病变介入治疗临床分析 (英文)

目的：分析冠状动脉慢性完全闭塞（CTO）病变患者经皮冠状动脉介入治疗（PCI）疗效的影响因素。方法：回顾分析我院2010年1月至2012年12月期间65例患者72处 CTO病变介入治疗的临床资料、病变特征和PCI的疗效。结果：CTO病变 PCI成功率为91.67%（66/72）;CTO病变闭塞时间＞12个月者 PCI成功率显著低于3～12个月者（81.48%比97.78%）,闭塞长度＞15mm的 CTO病变 PCI成功率显著低于闭塞长度≤15mm者（78.26%比97.96%）;断端呈刀切状的 CTO病变 PCI 成功率显著低于鼠尾状者（71.43%比96.55%）,P 均＜0.05;PCI失败有6处,其中4处因导丝未能通过病变,2处因球囊未能通过病变;介入术中并发症发生率为7.69%,住院期间均无主要不良心血管事件;术后心绞痛症状缓解率为90.16%。结论：冠状动脉慢性完全闭塞病变经皮冠状动脉介入治疗成功率与病变特征、CTO病变闭塞时间等因素有关。     

单支冠状动脉慢性完全闭塞病变介入治疗术后影响预后因素

目的：探讨单支冠状动脉慢性闭塞（CCTO）病变介入治疗术后临床预后的影响因素.方法：回顾分析2006年10月～2013年2月因单支主要冠状动脉CCTO病变在我院行经皮冠状动脉介入治疗（PCI）的患者资料,筛选预测主要不良心脏事件（MACE：心因性死亡、再发心绞痛、非致命性心肌梗死或心力衰竭）的危险因子.结果：130例患者平均中位年龄为68岁,男性占76.9％.86例（66.2％）被成功开通闭塞血管.平均随访23月,40例（30.8％）发生MACE事件,PCI失败并不增加MACE事件的发生（P=0.205）,多因素Logistic回归分析显示慢性肾脏疾病（CKD）≥3期和MACE事件独立相关（OR值1.55,95％可信区间1.07～2.24,P=0.02）.结论：肾功能失代偿（CKD≥3期）可预测单支主要冠状动脉慢性闭塞病变患者PCI术后的远期不良预后,成功的PCI治疗可能不能减少此类患者主要不良心脏事件的发生.     

Percutaneous coronary interventions and cardiovascular outcomes for patients with chronic total occlusions

相似文献   

Trends in outcomes after percutaneous coronary intervention for chronic total occlusions: a 25-year experience from the Mayo Clinic.

OBJECTIVES: The aim of our study was to examine the trends in procedural success, in-hospital, and long-term outcomes after percutaneous coronary intervention (PCI) for chronic total occlusions (CTO) over the last 25 years from a single PCI registry and to examine the impact of drug-eluting stents. BACKGROUND: The percutaneous treatment of CTO remains a major challenge. Past studies have used variable definitions of CTO, and there are limited data available from contemporary practice. METHODS: We evaluated the outcomes of 1,262 patients from the Mayo Clinic registry who required PCI for a CTO. The patients were divided into 4 groups according to the time of their intervention: group 1 (percutaneous transluminal coronary angioplasty era), group 2 (early stent era), group 3 (bare-metal stent era), and group 4 (drug-eluting stent era). RESULTS: Procedural success rates were 51%, 72%, 73%, and 70% (p < 0.001), respectively, in the 4 groups. In-hospital mortality (2%, 1%, 0.4%, and 0%, p = 0.009), emergency coronary artery bypass grafting (15%, 3%, 2%, and 0.7%, p < 0.001), and rates of major adverse cardiac events (8%, 5%, 3%, and 4%, p = 0.052) decreased over time. During follow-up, the combined end point of death, myocardial infarction, or target lesion revascularization, was significantly lower in the 2 most recent cohorts compared with those patients treated before (p = 0.001 for trend). Technical failure to treat the CTO was not an independent predictor of long-term mortality (hazard ratio 1.16 [95% confidence interval 0.90 to 1.5], p = 0.25). CONCLUSIONS: Procedural success rates for CTO have not improved over time in the stent era, highlighting the need to develop new techniques and devices. Compared with the prestent era, in-hospital major adverse cardiac events and 1-year target vessel revascularization rates have declined by approximately 50%.     

两种指引导丝操作技术治疗冠状动脉慢性闭塞性病变患者的疗效及安全性

目的 观察应用以球囊做支撑用普通指引导丝(中等硬度3～6 g)(球囊支撑组)及单独使用指引导丝(普通组)治疗冠状动脉(冠脉)慢性闭塞性病变(CTO)的可行性、安全性和效果.方法 经冠脉造影检查发现有CTO病变并行经皮冠脉介入(PCI)治疗的患者108例(陈旧性心肌梗死59例,不稳定型心绞痛22例,稳定型心绞痛27例).普组组65例,球囊支撑组43例,比较两组患者手术成功率、并发症发生率等.结果 108例CTO病变88例(81.5%)获得成功,20例(18.5%)未成功,普通组与球囊支撑组分别成功52例(80.0%)与36例(83.7%),两组比较差异无统计学意义 (P＞0.05).并发症普通组7例(10.8%)高于球囊支撑组的1例(2.3%)(P＜0.05).术中无死亡病例,术后住院期间无主要不良心脏事件(MACE)发生.结论 以球囊支撑普通指引导丝做CTO 安全方便.

Abstract：

Objective To observe the feasibility, safety and efficacy of percutaneous coronary intervention (PCI) for treatment of chronic total occlusions (CTO)by only the guidewire versus by the guidewire dependent on balloon. Methods The 108 patients with CTO confirmed by coronary angiography and treated with PCI from March 2009 to March 2011 were enrolled in this study, including 59 cases with old myocardial infarction, 22 unstable angina cases and 27 stable angina cases. The clinical data, outcomes of PCI, perioperative complications and incidence of major adverse cardiac events (MACEs) during follow-up were retrospectively analyzed between group A (only by the guide wire) and group B (by guide wire dependent on balloon). Results The 88 of 108 patients (81.5%) got successful operations. The success rate of CTO was a little higher in group B than in group A [80.0%(52/65) vs. 83.7%(36/43), P＞0.05]. The rate of total complications was more in group A than in group B [10.8%(7/65) vs. 2.3%(1/43), P＜0.05]. No death occurred during operation, no MACE occurred after operation in hospital and no patients underwent emergency coronary artery bypass graft (CABG) in the two groups. Conclusions The PCI for treatment of CTO used by the guidewire dependent on balloon shows a safety and effecary.     

慢性完全闭塞冠状动脉病变介入治疗的现状与挑战

冠状动脉慢性完全闭塞病变(CTO)是指冠状动脉100%闭塞且闭塞超过3个月的病变[1].CTO行经皮冠状动脉介入治疗(PCI)技术难度大、即刻成功率低、术后再闭塞和再狭窄发生率高,故被认为是目前PCI领域最大的障碍和挑战.近年来通过各国心脏介入专家的广泛交流与合作,在CTO专用器械研发、PCI手术技巧等方面都取得了很大的进展.     

Percutaneous recanalization of chronic total coronary occlusions: experience with the direct argon laser assisted angioplasty system (LASTAC)

The present study reports initial experience with the argon laser LASTAC system in patients with chronic coronary artery occlusion not amenable to recanalization with conventional systems. The LASTAC system conducts focused argon laser light through an optical fiber of 200 microns which is inserted through a multiple-lumen balloon catheter. The balloon serves the purpose of coaxially positioning the optical fiber. The balloon catheter is advanced by means of a guidewire to about 2 mm proximal to the occlusive lesion. After advancing the optical fiber, in three times 10 to 20 Joules are applied. Thereafter, the optical fiber is withdrawn, the balloon deflated, the catheter system repositioned and the sequence repeated. The integrity of the system with respect to temperature increase, energy loss and contact with tissue is monitored with lens fluorescence. In 29 patients with angina pectoris and documented ischemia, 30 complete occlusions were treated. In 18 (60%), there was successful recanalization with conventional balloon dilation thereafter. The total success rate for the right coronary artery was 55%, for the circumflex artery 71% and for the left anterior descending artery 67%. With regard to complications, in one patient there was nontransmural myocardial infarction, in seven there were asymptomatic dissections, one patient required defibrillation. The value of the LASTAC system for recanalization of chronically occluded coronary arteries has not yet been fully delineated. However, the success rate of 60% in previously treatment-refractory patients as well as the fact that no perforations were incurred, is encouraging. Further assessment will require analysis of long-term results as well as comparison of other methods.     

冠状动脉慢性完全闭塞病变的介入治疗

目的总结冠状动脉慢性完全闭塞病变经皮冠状动脉介入术的疗效。方法实施经皮冠状动脉介入术治疗冠状动脉慢性完全闭塞病变患者65例，回顾其临床资料、病变特征和经皮冠状动脉介入术的疗效。冠状动脉慢性完全闭塞病变靶血管共65支，平均闭塞时间为（10±5）个月，均按标准方法行球囊扩张及支架置入术。结果75％（49／65）的患者成功完成了冠状动脉内支架植入术，共植入金属支架58枚。随闭塞时间的延长，经皮冠状动脉介入术成功率显著降低（P=0．001），真性完全闭塞、残端形态圆钝形或刀切样改变、闭塞长度超过15mm都是经皮冠状动脉介入术低成功率的相关因素（P〈0．05）。所有病例住院期间均未发生主要不良心脏事件。结论冠状动脉慢性完全闭塞病变实施经皮冠状动脉介入术的技术难度较大，术前选择适当的病例和病变、正确选择和应用器械有利于提高成功率。     

冠状动脉慢性完全闭塞病变的介入治疗

目的 总结冠状动脉慢性完全闭塞病变经皮冠状动脉介入术的疗效.方法 实施经皮冠状动脉介入术治疗冠状动脉慢性完全闭塞病变患者65例,回顾其临床资料、病变特征和经皮冠状动脉介入术的疗效.冠状动脉慢性完全闭塞病变靶血管共65支,平均闭塞时间为(10±5)个月,均按标准方法行球囊扩张及支架置入术.结果 75%(49/65)的患者成功完成了冠状动脉内支架植入术,共植入金属支架58枚.随闭塞时间的延长,经皮冠状动脉介入术成功率显著降低(P=0.001).真性完全闭塞、残端形态圆钝形或刀切样改变、闭塞长度超过15 mm都是经皮冠状动脉介入术低成功率的相关因素(P＜0.05).所有病例住院期间均未发生主要不良心脏事件.结论 冠状动脉慢性完全闭塞病变实施经皮冠状动脉介入术的技术难度较大,术前选择适当的病例和病变、正确选择和应用器械有利于提高成功率.     

Therapeutic ultrasound for chronic total coronary artery occlusions

This article focuses on the use of catheter-delivered ultrasound as a device for treatment of coronary arterial total occlusion (CTO). The standard treatment of CTO is reviewed and serves as the basis for the need for new treatment options, such as catheter-delivered ultrasound (SONICROSS). The results of FDA-approved Phase I and Phase II clinical trials using SONICROSS for refractory CTO are described. The Phase II trials indicate that the SONICROSS-facilitated guidewire passage in 71% of CTOs are otherwise refractory to guidewire passage. However, at present, the SONICROSS catheter system is limited in its ability to be delivered reliably to the CTO because of catheter size and trackability.