前向技术开通冠状动脉慢性完全闭塞病变技巧

冠状动脉慢性完全闭塞病变(chronic total occlusion,CTO)手术成功率相对低,技术难度很大,术中并发症多,术后再狭窄发生率高,因此被认为是经皮冠状动脉介入(PCI)领域最大的困难和挑战。追究其失败原因,导引钢丝无法通过闭塞病变占绝大多数原因(63%～92%),其次是球囊无法通过病变,而导丝能否通过CTO病变与术者的经验及介入器材的选择有很大的关系。常用的开通CTO病变的技术包括前向导丝开通技术与逆向导丝开通技术。通常情况下,开通CTO病变首选前向导丝技术,逆向导丝技术只应用于前向导丝技术失败后的次要选择,但是有些患者的造影结果显示前向技术开通难度很大,如闭塞处为齐头且钙化较重,闭塞处有较大分支血管等,此时如闭塞处可利用的侧支循环血管好,可直接考虑行逆行导丝技术开通CTO病变。     

控制性正向和逆向导丝内膜下循径技术在逆向导丝介入治疗冠状动脉慢性闭塞性病变中的应用

目的:探讨控制性正向和逆向导引导丝内膜下循径(controlled antegrade and retrograde subintimal tracking,CART)技术在逆向介入治疗冠状动脉慢性完全闭塞(chronic total occlusion,CTO)病变中应用的效果.方法:回顾性分析我院2008年5月至2010年9月16例既往曾在外院和我院常规正向导丝技术行冠状动脉介入治疗(percutaneous coronary intervention,PCI)失败的患者,本次采用逆向导丝技术行PCI;术中逆行导丝或正向导丝无法通过闭塞病变部位且走行于血管内膜下时,利用正向或逆向导丝送入球囊扩张血管内膜下腔隙,以便对侧导丝能够进入扩大的内膜下腔隙,进而控制导丝经过闭塞段内膜下腔隙进入闭塞病变近段或远段血管真腔,随后完成常规冠状动脉介入治疗.结果:总结逆行导丝技术及经验,16例尝试CART技术的病例中15例获得手术成功,1例失败;未发生血管穿孔;所有患者住院期间无死亡.结论:CTO介入治疗根据CTO病变影像学特征,适时合理的采取CART技术能提高手术成功率.     

联合小外径球囊在逆行导丝技术治疗冠状动脉慢性完全闭塞病变中的应用

目的:观察联合1.25 mm的快速交换型(monorail)球囊和1.5整体交换型(over the wire,OTW)球囊在逆行导丝技术治疗慢性完全闭塞病变(chronical total occlusion,CTO)中的应用.方法:20例CTO患者闭塞病变的远端均有良好的侧支循环血管逆行供血,在行逆行导丝技术介入治疗前,仔细阅读造影图像,合理选择经间隔支形成的侧支循环血管,首先使用1.5 mm的OTW球囊供血血管内行超选择造影,以便了解侧支循环血管的走行,指引导丝成功逆行通过侧支血管,然后采用1.25 mm的monorail球囊全程顺序低压力(3～5 atm)扩张侧支循环血管.从而减少侧支血管对导丝前行的阻力,为1.5 mmOTW球囊或微导管通过创造条件,同时也为逆行扩张闭塞病变做准备.结果:所有1.25 mm的monorail球囊均成功扩张侧支血管,1.5 mm OTW球囊均逆行到达靶血管远端并完成靶病变的初次扩张,随后完成支架置入,术中所有患者均未出现房室传导阻滞、心包填塞等并发症.结论:结合目前现有的医疗器械,联合使用1.25 mm的monorail球囊和1.5 mm OTW球囊在逆行导丝技术治疗CTO中是有效的.     

冠脉边支血管超声引导下开通无残端分支CTO病变的临床研究

目的探讨冠脉边支血管超声引导下无残端分支冠状动脉慢性完全闭塞病变(CTO)介入开通手术治疗的临床效果。方法采用回顾性研究方式,选取2012年8月至2017年5月哈尔滨市第一医院介入治疗的无残端分支冠状动脉CTO患者16例,均在冠脉边支血管超声(IVUS)引导下完成经皮冠状动脉介入(PCI)治疗。观察介入治疗情况和效果。结果 IVUS引导下完成CTO残端导丝穿刺的患者13例,成功率为81.25%;在CTO残端导丝穿刺成功后经由阻塞血管进入真腔的患者11例(68.75%); CTO残端导丝穿刺成功后没有进入真腔的2例患者,均选择逆向导丝穿刺方法完成CTO开通治疗。穿刺成功的13例患者均首先选择常规PCI导丝进行CTO残端导丝穿刺,1例患者未成功到达远端真腔,改为逆向导丝穿刺术后成功,其余12例患者均选择CTO专用导丝进行穿刺后,成功完成开通手术。结论冠状动脉IVUS引导下完成无残端分支冠状动脉CTO介入开通手术具有较好的效果,而CTO专用导丝的硬度相对较高,治疗效果优于常规导丝。     

冠状动脉慢性完全闭塞病变介入治疗临床疗效分析

目的:探讨国人冠状动脉慢性完全闭塞病变(CTO)患者的介入治疗特点及影响因素。方法:入选2017年中国冠状动脉慢性闭塞病变俱乐部(CTOCC)的CTO患者40例,分析介入治疗过程的特点以及操作成功率。结果:40例患者闭塞时间为3~56个月,均为首次介入治疗失败者,J-CTO评分均≥3分,术前均行冠状动脉CT检查,双侧造影使用率为100%。通过前向技术成功开通血管23例,血管内超声(IVUS)指导下正向钢丝技术及平行导引钢丝技术为术者最常采用的正向技术,其中5例患者采用正向内膜下重回真腔(antegrade dissection reentry,ADR)技术4例获得成功;逆向导丝通过法成功完成介入治疗14例,使用Reverse CART技术10例。术中使用平均钢丝数为5.07根,术者最常用软导丝是Sion系列钢丝35例(82.5%),其次为Runthrough钢丝22例(55%),再次为锥形导丝Fielder系列钢丝15例(37.5%),成功通过病变5例(12.5%)。使用硬导引钢丝通过病变32例(80%),通过CTO病变术者最常使用的硬导引钢丝为Gaia系列钢丝23例(57.5%),其次为Conquest系列导引钢丝19例(47.5%),再者为Pilot系列钢丝18例(45.0%)。术中微导管使用率为100%,其中Cosair导管最常使用(33例,82.5%)。操作中IVUS使用22例(55%),主要用于判断导丝远端是否位于真腔、植入支架时管腔直径判断及寻找闭塞血管入口。40例患者平均球囊使用3.24个,平均植入支架2.53个,均为药物洗脱支架,PCI成功37例,未成功3例,PCI成功率达92.5%。住院期间无主要心血管不良事件发生。结论:2017年CTOCC病例介入治疗成功率高于目前国内外CTO介入治疗的平均成功率;这得益于术者经验丰富、术前充分阅片、冠脉CT使用率高、术中IVUS充分使用以及合理的使用导丝、器械及合理的策略选择。     

扩张微导管联合新型慢性闭塞病变专用导丝在冠状动脉慢性完全闭塞病变介入治疗中的有效性与安全性探讨

目的研究扩张微导管(corsair微导管)联合新型慢性闭塞病变专用导丝在冠状动脉慢性完全闭塞(CTO)病变介入治疗中的有效性与安全性并进行探讨。方法选取从2012年3月至2015年2月治疗的CTO病变患者,其中使用扩张微导管联合新型CTO病变专用导丝介入治疗的64例为观察组,采用传统治疗的64例为对照组。对比两组操作成功率、逆向技术使用情况、手术时间、对比剂用量、造影时间并发症发生率及术后1年严重不良心血管事件发生率。结果观察组操作成功率为89.06%(57/64),显著高于对照组的70.31%(45/64)(P0.05);观察组手术时间(105.3±58.5 min)、对比剂用量(254.9±96.3 ml)以及造影时间(62.8±24.7 min)均显著低于对照组(143.7±42.4 min,334.2±104.7 ml,79.3±32.6 min,P0.05);且观察组术中并发症发生率(4.69%)以及术后1年严重不良心血管事件发生率(1.56%)均明显低于对照组(32.81%,17.19%),差异均有统计学意义(P0.05)。结论扩张微导管联合新型慢性闭塞病变专用导丝在冠状动脉CTO病变介入治疗中能提高介入操作成功率,降低并发症发生率,安全性较佳。     

应用螺纹穿通导管治疗冠状动脉慢性完全闭塞病变

目的探讨螺纹穿通导管(Tornus)在冠状动脉慢性完全闭塞病变介入治疗中的应用价值。方法对我院收治的导丝能通过而最小径球囊导管不能通过的冠状动脉慢性完全闭塞病变5例的临床资料进行分析并复习相关文献。结果 5例均采用Tornus导管通过闭塞段血管,球囊导管成功扩张后置入合适支架,完成血管重建,手术时间1.0~3.0(1.9±0.7)h,造影剂用量150~300(240±42)ml。术中、术后及随访无并发症及死亡事件发生。结论 Tornus导管有助于治疗导丝能通过而球囊导管不能通过的冠状动脉慢性完全闭塞病变,提高介入治疗成功率,且操作简单,并发症少。     

药物洗脱支架在慢性完全闭塞冠状动脉病变中的临床应用

目的:总结药物洗脱支架(DES)在慢性完全闭塞冠状动脉病变(CTO)中的临床应用.方法:对2003年1月至2005年5月实施经皮冠状动脉介入治疗(PCI)的38例CTO患者的临床资料、病变特征和PCI结果进行回顾性分析.共涉及CTO靶血管47支,CTO平均闭塞时间(18.1±10.6)个月,置入DES 32枚.结果:病例成功率为65.8%(25/38),病变成功率为61.7%(29/47).随CTO闭塞时间延长,PCI成功率降低,闭塞部位呈刀切状,存在桥侧支的CTO病变PCI成功率降低(P＜0.05).操作失败13例,其中46.2%因导丝不能通过CTO病变,53.8%因球囊不能跨越病变.术中无死亡病例,因导丝进入内膜下导致病变处桥侧支急性关闭3例,心包穿孔2例.术后住院期间死亡1例,再发急性心肌梗死1例,总的主要不良心脏事件发生率为5.2%(2/38).结论:在冠状介入新器械和新技术的发展下,DES治疗CTO病变可获得安全和有效的临床效果.     

经桡动脉成功介入治疗103例单支冠状动脉慢性闭塞病变的体会

目的探讨经桡动脉成功介入治疗单支冠状动脉慢性闭塞（CTO）病变的临床体会。方法回顾分析经桡动脉成功介入治疗单支CTO病变103例患者的临床资料。结果（1）103例患者中不稳定型心绞痛57例,稳定型心绞痛12例,陈旧性心肌梗死34例;病变闭塞时间≤6个月83例,病变闭塞时间〉6个月20例;（2）103例患者的介入路径血管均无严重迂曲及解剖结构变异,左前降支闭塞51例,左回旋支闭塞25例,右冠状动脉闭塞27例;慢性完全性闭塞24例,慢性功能性闭塞79例;边支无闭塞病变91例,无侧支形成87例,病变长度〈15mm67例,锥形病变81例;（3）最终完成介入术的Judkins、XB、EBU导引导管所占比例分别为37．86％、30．10％、29．13％;（4）成功通过病变的PILOT系列导引钢丝为64．08％;（5）首次通过病变并成功实施预扩张的1．25mm直径系列球囊57例（55．34％）,1．5mm直径系列球囊38例（36．89％）。结论在术者经验丰富的基础上经桡动脉介入处理单支CTO病变可行,其成功介入与介入路径畅通无阻、靶血管具备特征性病变特点及合理选择器械密不可分。     

逆向导丝技术介入治疗冠状动脉慢性完全闭塞病变的术中护理

目的：探讨逆向导丝技术介入治疗冠状动脉慢性完全闭塞病变（CTO）的术中护理。方法对15例CTO患者行逆向导丝技术介入治疗时，密切观察心电、血压及病情变化，加强活化凝血时间的监测，及时准确的处置术中各种情况，同时给予心理支持。结果15例患者中，有6例因PTCA导丝无法通过闭塞病变而放弃介入治疗，另9例成功完成手术。15例患者中，有2例术中出现一过性心率、血压下降；1例穿隔支侧枝破损；1例慢血流。结论CTO病变的逆向导丝介入技术难度大，风险高，护理人员应具备丰富的心脏介入知识，敏锐的观察力、专业的救治力，以确保手术顺利完成。     

Percutaneous coronary stenting in guide-induced aortocoronary dissection: angiographic and CT findings

We report here on a case of accidental aortocoronary dissection that occurred during the engagement of a guiding catheter. This resulted in an antegrade dissection into the right coronary artery, and a retrograde extension of the dissection into the Sinus of Valsalva and the ascending aorta up to the aortic arch. It was successfully treated with a stent deployment at the RCA ostium; this restored optimal coronary blood flow and there was a complete resolution of the aortic dissection as was documented by coronary angiography and the follow-up CT scan.     

Retrograde approach to coronary chronic total occlusion via an occluded saphenous bypass graft: a case report

Retrograde coronary intervention of chronic total coronary occlusion remains challenging. We describe a successful retrograde intervention of chronically occluded right coronary artery ostium via an occluded vein graft. An occluded saphenous vein graft can be a useful means to access the distal coronary bed, enabling delivery of retrograde percutaneous coronary intervention (PCI) equipment.     

Ultrasound-Guided Peripheral Intravenous Access in the Emergency Department Using a Modified Seldinger Technique

Background: The utility of ultrasound-guided peripheral intravenous access (USGPIV) has been well described. However, few studies have investigated USGPIV techniques. Objectives: To describe a modified Seldinger technique for USGPIV. Methods: Emergency Department patients with difficult i.v. access (three or more failed landmark attempts) were prospectively enrolled. USGPIV was attempted using modified Seldinger technique. A 20-gauge, 3.81-cm catheter with integral wire was used for all procedures. The basilic vein was identified using a high-frequency linear probe (5–10 MHz). The needle was inserted into the vein with dynamic guidance in short axis, and the cannula was advanced over a wire. Time from skin puncture to catheter insertion, number of needle sticks, and overall procedure time were recorded. Results: Twenty-five patients were enrolled and underwent USGPIV; success rate was 96% (24/25). The mean number of needle sticks was 1.32 (95% confidence interval 1.12–1.52). Median time from skin to catheter insertion was 68 s (± SD 70.5 s). Median total procedure time was 7 min (420 s) (± SD 5.23 min). Conclusions: Modified Seldinger technique is an effective method of USGPIV and is worthy of a prospective comparison with non-Seldinger technique.     

Rolling filling defect?

A 68-year-old man was admitted with intermittent chest tightness. Coronary angiography revealed subtotal occlusion of right coronary artery (RCA). After successful stenting from middle to proximal RCA with two Cypher stents, angiography showed a “Rolling filling defect” at distal aneurysmal dilatation of RCA. Intravascular ultrasound (IVUS) confirmed the “Rolling filling defect” as a trapped air bubble just in RCA distal aneurysm. By using a 2.5 × 20 mm balloon anchoring at distal RCA, a 5Fr. ST01 catheter was advanced into distal RCA and aspirated the “Rolling filling defect” successfully. The case highlights the importance of preventing iatrogenic trapped air bubble in usual daily practice. Once it happens, several devices may utilize for aspiration including “5 in 6” aspiration technique or thrombo-suction catheters. Furthermore, IVUS can help for differential diagnosis in such scenario.     

Application of a rapid exchange extension catheter technique in type B2/C nonocclusive coronary intervention via a transradial approach

BACKGROUNDIn transradial intervention procedures, poor back-up support and noncoaxial alignment of the guide catheter (GC) may result in failure of the balloon or stent to reach the targeted lesion. Methods to provide extra back-up support using the original GC and wire can improve procedural success with reduced complications. A rapid exchange guide extension catheter provides convenient and efficient back-up support while preserving the initial GC and inserted wire.AIMTo evaluate the efficacy and safety of rapid exchange extension catheter in the treatment of type B2/C nonocclusive coronary lesions via the radial access.METHODSA total of 135 patients with type B2/C nonocclusive lesions who were treated via the transradial approach were enrolled in the study. The clinical characteristics, indications for use of the rapid exchange extension catheter, and procedural details and results were reviewed and analyzed. All procedure-related complications and major adverse cardiovascular events were recorded during the in-hospital stay and follow-up period.RESULTSThe most common indication for the use of a rapid exchange extension catheter was vascular tortuosity (37.8%), followed by heavy calcification (28.9%), long lesions (20.0%), proximal stent (6.7%), in-stent restenosis (5.2%), and coronary origin anomalies (1.5%). The following technologies failed in passing targeted lesions before delivering the rapid exchange catheter: Multiple predilatation technique (57%), buddy wire technique (33.4%), balloon anchoring technique (5.9%), and cutting balloon modification (3.7%). The mean depth of the extension catheter intubation was 20.56 ± 13.05 mm, and the mean rapid exchange catheter service time was 18.9 ± 9.7 min. The mean length and diameter of stents were 33.5 ± 14.4 mm and 2.75 ± 0.45 mm, respectively. The total rate of technique success (balloon or stent successful crossing of the target lesion with this technique) was 94.8%.CONCLUSIONThe rapid exchange extension catheter technique showed acceptable safety and efficacy in the transradial coronary interventions of type B2/C nonocclusive coronary lesions. We recommend this technique to assist in complex lesion intervention via radial access.     

Preprocedural coronary CT angiography significantly improves success rates of PCI for chronic total occlusion

Chronic total occlusions of coronary arteries occur in about 20 % of patients with suspected coronary artery disease and are more frequent with increasing age. The success rate of interventions is lower (55–80 %) compared to conventional lesions (>90 %). Coronary CT angiography (coronary CTA) provides information about the occluded segment, which cannot be obtained from invasive angiograms (XA). We therefore hypothesized that preprocedural coronary CTA may improve success rates of percutaneous coronary intervention (PCI) for coronary arteries (CTO). 30 patients with chronic total coronary artery occlusions (mean age 73 years, 26 men) and predicted high complexity were imaged by coronary CTA prior to PCI for CTO. CT data sets were acquired with a 64 detector row dual source scanner and retrograde ECG gating, 0.6 mm collimation and z-flying focal spot, yielding isovoxel spatial resolution of about 0.4 mm. Based on the CT data sets, established complexity criteria for CTO (Euro CTO club, Di Mario et al. in EuroIntervention 3(1):30–43, 2007) were evaluated and compared to invasive coronary angiography. Three-dimensional volume-rendered images of the occluded coronary artery were displayed in the catheterization lab during PCI to guide the advancement of the wire. PCI success, defined as the ability to advance the guide wire into the distal lumen with thrombolysis in myocardial infarction III flow was compared to 43 controls without coronary CTA using propensity score matching based on established criteria of procedural success. The course of the occluded segments was visualized by coronary CTA in all cases. Calcification, lesion length, stump morphology and presence of side branches were underestimated by invasive angiograms when compared to coronary CTA. PCI success rate in 30 patients who underwent pre-procedural CTA was significantly higher than in patients without prior coronary CTA [unmatched: CT 90 % (27/30) vs. no CT 63 % (27/43), p = 0.009; matched: CT 88 % (22/25) vs. no CT 64 % (16/25) p = 0.03]. Through information not readily seen on invasive coronary angiography, coronary CTA can significantly enhance success rates of PCI for CTO.     

Pacemaker Electrode Repositioning Using the Loop-Snare Technique

Using a percutaneous femoral vein approach under fluoroscopic control, a malpositioned ventricular pacemaker electrode was released from the right ventricular wall by hooking the lead with a deflecting wire inserted into a RIM catheter. A closed loop was formed by tightening the handle of the wire allowing the electrode to be dislodged and pulled into the inferior vena cava. The electrode was then snared using a loop formed by an exchange wire advanced through an 8 French catheter with a J-curve steamed at its tip. The electrode was advanced to the right ventricular apex and released by advancing one end of the snare wire while pulling the other end to open the loop.     

Endoscopic ultrasound-assisted rendezvous maneuver to achieve pancreatic duct drainage in obstructive chronic pancreatitis

Patients with mechanical obstruction of the pancreatic duct, which can be caused by chronic pancreatitis, suffer from recurrent attacks of pain and inflammation of the pancreas. We report a novel approach using an endoscopic ultrasound- (EUS-) assisted rendezvous technique, which allows drainage of the pancreatic duct in patients in whom primary management by transpapillary drainage during an endoscopic retrograde cholangiopancreatography (ERCP) procedure has failed. Transgastric puncture of the pancreatic duct was performed using a 19-gauge needle under EUS guidance, and a 0.035-inch guide wire was introduced into the duct and advanced through the papilla. This wire was pulled into the duodenum using a side-viewing duodenoscope. A papillotomy was performed using the standard technique and a plastic prosthesis was introduced. The patient tolerated the intervention well and was discharged with no further complaints. EUS-assisted drainage of the pancreatic duct using a rendezvous technique is an elegant and feasible minimally invasive endoscopic treatment for symptomatic patients with chronic pancreatitis, in whom transpapillary introduction of a catheter is not possible.     

Transcystic duct treatment of common bile duct stones

Successful removal of 2 retained common bile duct stones following cholecystostomy is described. With the use of the steerable catheter and the wire basket, one stone was crushed and the second was extracted in retrograde fashion through the cystic duct and gallbladder.     

Slender PCI

Currently the 0.014-inch guidewire is commonly used for coronary intervention and all devices are 0.014 inch-compatible. The size of common guiding catheters is 6Fr. However, PCI requires oral administration of dual antiplatelet agents, and punctured-site complications such as hemorrhage and hematoma occur more frequently with use of a 6Fr guiding catheter compared to a 5Fr guiding catheter. Moreover, 6Fr or larger guiding catheters may cause radial arterial occlusion, although the transradial approach causes less punctured-site complications compared to the transfemoral approach. Recently, 0.010-inch guidewires applicable for the kissing balloon technique (KBT) using a 5Fr guiding catheter and 0.010-inch guidewire-compatible balloons have been developed in Japan, and a 3Fr angiography catheter has also been developed. We refer to these devices as the "slender system", and we have used this system for active treatment of bifurcation lesions and chronic total occlusion (CTO). In this report, we describe angiography using a 3Fr catheter, the KBT using a 5Fr guiding catheter and 0.010-inch guidewires, and treatment of CTO using a 5Fr catheter and 0.010-inch guidewires. For CTO treated using the slender system at our facility, the transradial arterial approach was used in 90.7% of cases, treatment using the slender system alone succeeded in 65.1%, and the overall success rate was 89.5%. Therefore, our results show that complex lesions may be treatable using the slender system, and that not all complex lesions require a 6Fr or larger guiding catheters, a femoral arterial approach, or bilateral guiding catheters.