闭塞性冠状动脉病变PTCA成功率及影响因素

目的探讨完全闭塞性和几乎完全闭塞性病变ＰＴＣＡ成功率及其影响因素。方法对３５例发生过心肌梗塞和２１例未发生心肌梗塞的完全或几乎完全闭塞性病变施行了ＰＴＣＡ。结果完全闭塞性病变心梗发生后１周内ＰＴＣＡ成功率为１００％,２周～３个月为６６．７％,３个月以后为４２．９％;无桥侧支的几乎完全闭塞性病变ＰＴＣＡ成功率为１００％,桥侧支丰富的几乎完全闭塞性病变ＰＴＣＡ成功率为６２．５％。结论心肌梗塞早期ＰＴＣＡ成功率明显高于心肌梗塞晚期ＰＴＣＡ成功率（Ｐ＜０．０５）,无桥侧支的几乎完全闭塞性病变ＰＴＣＡ成功率明显高于桥侧支丰富的几乎完全闭塞性病变的成功率（Ｐ＜０．０５）     

Probe angioplasty of total coronary occlusion using an intracoronary Probing Catheter

Coronary angioplasty (PTCA) of total coronary occlusion is limited by the inability of guidewires and conventional dilating catheters to cross all such lesions. We have therefore developed a technique for PTCA of chronic total coronary occlusions using the ultralow profile "balloon-on-a-wire" Probe. An intracoronary Probing Catheter is used to facilitate crossing the stenosis with a guidewire and then to deliver a Probe into the obstruction for balloon dilatation. This technique was used in 13 patients including six in whom other dilating systems had failed to cross the occlusion. Successful dilatation was performed in nine patients (67%). Among the six patients in whom other dilating systems had failed, dilatation was performed in five using the Probing Catheter technique with a successful outcome achieved in four (67%). The Probing Catheter technique offers a promising new method to apply "balloon-on-a-wire" technology to the dilatation of chronic total coronary occlusions. This method may allow successful dilatation when other dilating systems fail.     

Angioplasty in total coronary artery occlusion

Percutaneous transluminal coronary angioplasty was attempted without streptokinase in 24 patients with total coronary artery occlusion but without acute transmural myocardial infarction. The maximal duration of occlusion was estimated to be 1 week or less in 10 patients, more than 1 to 4 weeks in 6, more than 4 to 12 weeks in 3 and more than 12 weeks in 5. Dilation of the occluded artery was attempted in the left anterior descending coronary artery in 17 patients, in the right coronary artery in 4 and in the circumflex coronary artery in 3. Angioplasty was successful in 13 patients (54%): left anterior descending coronary artery in 59%, right coronary artery in 50% and circumflex coronary artery in 33%. In patients with successful dilation, there was a mean decrease in coronary artery stenosis from 100 to 23%. In the 19 patients whose occlusion was estimated to be of 12 weeks' duration or less, angioplasty was successful in 68%. In the five patients whose occlusion was estimated to be of more than 12 weeks' duration, dilation was not successful in any (p = 0.006). It is concluded that in selected patients with symptomatic coronary artery disease and recent coronary artery occlusion without associated acute myocardial infarction, percutaneous transluminal coronary angioplasty alone may be effective in restoring patency.     

Spontaneous occlusion of a congenital coronary artery fistula

Cardiac catheterisation of a 6-month-old asymptomatic infant with a continuous precordial murmur revealed a congenital coronary artery fistula draining into the right ventricle. Following a period with no complications and the disappearance of the cardiac murmur, recatheterisation at the age of 4 years showed spontaneous complete closure of the fistula. This case in connection with 3 similar cases from the literature suggests that in asymptomatic patients with a congenital coronary artery fistula surgery might be delayed until school age in order to give spontaneous closure a chance.     

Angioplasty in total coronary arterial occlusion

Percutaneous transluminal coronary angioplasty (PTCA) was attempted in 67 patients with total coronary arterial occlusion but without associated acute transmural infarction. No patient received concomitant streptokinase therapy. The duration of occlusion was one week or less in 22 patients, one week to one month in 24 patients, one to three months in 13 patients, and more than three months in eight patients. The occluded vessel was the left anterior descending artery in 38 (57%), the right coronary artery in 22 (33%), and the circumflex coronary artery in seven (10%). A steerable system was used in 29 patients whereas a fixed guide wire system was used in 38. Dilation was successful in 44 patients (66%). When a steerable system was used, PTCA was successful in 76% of the patients, compared with 58% when a nonsteerable system was used. The average size of stenosis after dilation was 32%. In the patients with a recent occlusion (one week or less in duration), PTCA was successful in 82%, which was significantly better than in patients with an older occlusion (greater than 12 weeks), in whom dilation was successful in only 25% (p less than 0.01). In patients with an occlusion of one to three months, PTCA was successful in 65%. During a mean follow-up of 1.6 years in the 44 patients with successful dilation, 37 were asymptomatic without angina, although five had required repeat dilation or coronary bypass surgery. In selected patients with symptomatic coronary artery disease and recent coronary occlusion but without associated myocardial infarction, PTCA alone is an effective means of restoring flow. After successful dilation, the majority of patients remain asymptomatic.     

多层螺旋CT指导下慢性闭塞病变的介入治疗

目的探讨多层螺旋CT(MDCT)对于慢性闭塞(CTO)病变PCI结果有无指导作用。方法选择在我院行冠状动脉MDCT证实为冠状动脉CTO,并在我院心内科行择期PCI的冠心病患者35例。根据CT图像判断CTO病变的位置、性质及钙化程度,闭塞血管远段血流分级以及闭塞近段管腔直径等指标是否对PCI结果及操作时间有预测及指导意义。结果 35例患者中有37支闭塞血管,其中21支(56.8%)获得再通,未再通血管中43.8%位于右冠状动脉,56.2%位于血管近段,钙化斑块占56.2%,80.0%的血管在CT图像上无法看到闭塞远段造影剂渗漏。TIMI血流(P=0.0128)及闭塞部位血管病变的性质(P=0.0703)是CTO病变再通的影响因素。闭塞血管所处节段(P=0.0157)以及闭塞血管所处位置(P=0.0704)是开通CTO病变操作时间的影响因素。结论MDCT可以准确判断CTO病变的走行,评价其斑块的性质及分布。闭塞病变远段有无血流及斑块的性质是PCI是否成功的预测因素。闭塞血管的不同以及所处节段的不同是PCI操作时间长短的预测因素。     

经皮冠状动脉介入术治疗冠状动脉慢性完全闭塞性病变疗效

目的 总结经皮冠状动脉介入术治疗冠状动脉慢性完全闭塞(chronic total occlusion,CTO)的疗效.方法 回顾性分析2006年12月前施行经皮冠状动脉介入术的临床资料.结果 冠状动脉慢性完全闭塞233例,共有靶血管251支,闭塞时间(20±10)个月.226例(226/251,96.9%)的237处靶病变(237/251,94.4%)行经皮冠状动脉介入术成功.共植入冠状动脉支架266枚.因导丝不能通过CTO病变未成功7例:造影提示病变类型均为旁路侧支血管丰富型或多处长的弯曲病变,其中2例闭塞时间有5年以上,另5例未开通患者中有2例因心功能不全不能耐受长时间手术而终止操作.术中及术后均无严重并发症.术后心绞痛症状缓解率85.4%.心功能改善率79.6%,5年生存率88.9%.结论 冠状动脉慢性完全闭塞行经皮冠状动脉介入术成功关键在于熟练的操作技术、合理的器材选择及仔细评估病人和动脉闭塞病变状况;开通闭塞动脉可显著改善患者临床症状,提高生活质量.     

经皮冠状动脉介入术治疗冠状动脉慢性完全闭塞性病变疗效

目的总结经皮冠状动脉介入术治疗冠状动脉慢性完全闭塞（chronic total occlusion，CTO）的疗效。方法回顾性分析2006年12月前施行经皮冠状动脉介入术的临床资料。结果冠状动脉慢性完全闭塞233例．共有靶血管251支，闭塞时间（20±10）个月。226例（226／251，96．9％）的237处靶病变（237／251，94．4％）行经皮冠状动脉介入术成功。共植入冠状动脉支架266枚。因导丝不能通过CTO病变未成功7例：造影提示病变类型均为旁路侧支血管丰富型或多处长的弯曲病变，其中2例闭塞时间有5年以上，另5例未开通患者中有2例因心功能不全不能耐受长时间手术而终止操作。术中及术后均无严重并发症。术后心绞痛症状缓解率85．4％，心功能改善率79．6％，5年生存率88．9％。结论冠状动脉慢性完全闭塞行经皮冠状动脉介入术成功关键在于熟练的操作技术、合理的器材选择及仔细评估病人和动脉闭塞病变状况；开通闭塞动脉可显著改善患者临床症状，提高生活质量。     

Current percutaneous recanalization of coronary chronic total occlusion

Although successful recanalization rates of coronary chronic total occlusions have remained suboptimal in percutaneous coronary interventions, evolving techniques, including the retrograde approach, have raised hopes for better outcomes. With the advent of antiplatelet therapy and drug-eluting stents, along with conventional antegrade approaches, further progress can be expected in the "last frontier" of interventional cardiology. The article focuses on contemporary recanalization strategy in percutaneous coronary intervention of coronary chronic total occlusions.     

Probe angioplasty of total coronary occlusion using an intracoronary probing catheter™

Coronary angioplasty (PTCA) of total coronary occlusion is limited by the inability of guidewires and conventional dilating catheters to cross all such lesions. We have therefore developed a technique for PTCA of chronic total coronary occlusions using the ultralow profile “balloon-on-a-wire” Probe?. An intracoronary Probing Catheter? is used to facilitate crossing the stenosis with a guidewire and then to deliver a Probe into the obstruction for balloon dilatation. This technique was used in 13 patients including six in whom other dilating systems had failed to cross the occlusion. Successful dilatation was performed in nine patients (67%). Among the six patients in whom other dilating systems had failed, dilatation was performed in five using the Probing Catheter technique with a successful outcome acieved in four (67%). The Probing Catheter technique offers a promising new method to apply “balloon-on-a-wire” technology to the dilatation of chronic total coronary occlusions. This method may allow successful dilatation when other dilating systems fail.     

Percutaneous transluminal coronary angioplasty for chronic total coronary arterial occlusion

Experience is reported with 100 consecutive patients in whom percutaneous transluminal coronary angioplasty (PTCA) was attempted on chronically occluded coronary arteries that had no visible anterograde flow. Ninety-eight patients had angina and all had collateral vessels to the occluded artery on angiography. A movable guidewire/dilatation system was used in all cases. Overall initial PTCA success rate was 56% and was related to duration of occlusion (69% success rate for occlusions of 1 month or less, 50% for 1 to 6 months and 11% after 6 months). Complications were minor; no patient died or required emergency bypass operation. Of the 44 patients in whom PTCA failed, 20 underwent elective bypass surgery for relief of angina and 24 were treated medically. Follow-up at a mean of 8 months (range 1 to 48) was available for 49 of the 56 patients in whom PTCA was successful: 40 had subjective improvement, 6 no change and 3 felt worse. Control angiography was carried out in 40 of the 56 patients with primary success and showed long-term success in 18 and reocclusion or significant stenosis in 22. Of these 22, 11 were successfully treated by a second PTCA, 2 underwent operation and 9 were treated medically. Recanalization of totally occluded coronary arteries with no forward flow has a lower initial success rate (56%) than PTCA for stenoses and the recurrence rate is higher (55%), but effective relief of angina is achieved in successful cases. The risk of serious complications appears to be low.     

Chronic total coronary occlusion dis-obstruction by balloon angioplasty

Ninety-three consecutive patients with chronic total coronary occlusion underwent an attempted mechanical des-obliteration by percutaneous coronary angioplasty with a balloon catheter. The global results were 55 p. 100 initial successes (residual stenosis less than 50 p. 100). The good prognostic factors were: 1) left coronary artery, especially left circumflex artery occlusion p less than 0.50, and 2) the proximity to the date of occlusion as assessed from the clinical history or by the occurrence of occlusion between the time of diagnostic coronary angiography and angioplasty. In cases of recent occlusion dating less than one month, the success rate was high: 69 p. 100. On the other hand, there were no successes in occlusions of over 6 months standing. The presence of myocardial infarction did not influence the results. There were few complications (7 p. 100) and these did not include any deaths or cases requiring emergency surgery. Exercise stress tests were carried out after the procedure and were negative in 28 out of 32 patients (88 p. 100). Forty-three patients successfully revascularised were followed up for 1 to 48 months (average 9 months) after angioplasty. Thirty-one patients were asymptomatic. Of the 12 symptomatic patients, 7 underwent exercise stress tests (6 positive) and all had control angiography which showed restenosis in 10 cases with 5 occlusions. Percutaneous coronary angioplasty of recent total coronary occlusions gives good initial results without major complications, and the medium term clinical results are satisfactory.     

冠状动脉完全闭塞病变的介入治疗

目的观察急性和慢性冠状动脉闭塞经皮冠状动脉腔内成形术（ＰＴＣＡ）治疗的效果。方法３２例患者共３８支完全闭塞血管进行了ＰＴＣＡ或ＰＴＣＡ＋支架治疗。结果１２例急性心肌梗塞（ＡＭＩ）其中４例直接和８例行补救性ＰＴＣＡ均成功（１２／１２,１００％）;２０例择期ＰＴＣＡ中１４例成功（７０％）。结论血管闭塞时间越长,ＰＴＣＡ成功率越低。本组病例无一例出现严重并发症,表明冠状动脉完全闭塞行ＰＴＣＡ＋支架治疗是安全有效的。     

Drug-eluting stent-supported percutaneous coronary intervention for chronic total coronary occlusion.

OBJECTIVES: This study sought to determine the clinical and angiographic outcomes after drug-eluting stent (DES)-supported percutaneous coronary intervention (PCI) for chronic total coronary occlusion (CTO). BACKGROUND: There are few data about the efficacy of DES-supported PCI for CTO. METHODS: All consecutive patients who had a sirolimus-eluting stent or a paclitaxel-eluting stent implanted for CTO from December 2003 to December 2004 were analyzed. Clinical and angiographic outcomes of patients treated with DES were compared with a case-matched control group of patients treated with bare metal stents (BMS) in the 12 months before the routine use of DES. RESULTS: Successful DES-supported PCI was performed in 92 patients and 104 CTO. The case-matched control group consisted of 26 patients and 27 CTO successfully treated with BMS. There were no differences between groups in baseline clinical and angiographic characteristics. Stent length in the DES group was higher as compared with that of BMS group (51+/-28 mm vs. 40+/-19 mm, P=0.073). The 6-month major adverse cardiac event (MACE) rate was lower in the DES group as compared with that of BMS group (9.8% vs. 23%, P=0.072). The angiographic follow-rate was 80% in the DES group and 81% in the BMS group. The 6-month restenosis rate was 19% in the DES group and 45% in the BMS group (P<0.001). By multivariate analysis, it was found that in the DES group, the only predictors of restenosis were stented segment length (OR 1.031, 95% CI 1.01-1.06, P=0.009) and a target vessel reference diameter<2.5 mm (OR 6.48, 95% CI 1.51-27.83, P=0.012), while the only predictor of MACE was stent length (OR 1.04, 95% CI 1.01-1.08, P=0.006). CONCLUSIONS: DES implantation for CTO decreases the risk of mid-term restenosis and MACE. Small vessels and diffuse disease requiring the implantation of multiple stents and very long stents for full coverage of the target lesion are still associated with a relatively high risk of restenosis.