经皮冠状动脉介入治疗慢性完全闭塞病变57例

冠状动脉(冠脉)介入治疗中约有10%~20%属于慢性完全闭塞病变(CTO),由于开通此类血管的手术难度大,技术要求高,成功率低,术后近期再闭塞率和远期再狭窄的发生率均较高,因此成为心脏介入手术中较难处理的问题。我们回顾性分析57例CTO病变患者的临床资料。对象与方法1.对象:我院2002年10月~2005年4月我院行选择性冠脉造影患者共825例,其中CTO病变57例(6.9%),男42例(73.7%),女15例(26.3%),平均年龄57.8岁±8.4岁。临床表现为不稳定型心绞痛32例(56.1%);有心肌梗死者48例(84.2%),心电图检查有定位性病理性Q波者36例(63.2%),包括前壁心肌梗死1…     

经皮冠状动脉介入治疗慢性完全闭塞病变对患者心脏功能的影响

目的:观察行经皮冠状动脉介入(PCI)治疗成功开通慢性完全闭塞(CTO)病变是否能改善患者的心脏功能.方法:回顾性纳入我院2016年1月-2018年1月行冠状动脉造影证实单支CTO病变且接受PCI治疗的患者132例,根据CTO是否开通,将所纳入患者分为开通组(70例)和未开通组(62例).收集患者的基本临床资料,记录并...     

逆向经皮冠状动脉介入治疗左前降支的慢性完全闭塞病变

患者男,42岁,反复胸部不适2年,加重数个月,行走500 m后胸部压榨感。既往吸烟史,每天2包以上。     

慢性完全闭塞病变介入治疗进展与展望

随着新型介入器械的出现和介入技术的提高,慢性完全闭塞病变介入治疗仍然是目前介入治疗的难点和热点。现就相关最新进展做一综述。     

女性患者慢性完全闭塞病变经皮冠状动脉介入治疗的研究进展

慢性完全闭塞病变(chronic total occlusion,CTO)是指冠状动脉的完全闭塞,TIMI血流0级,且闭塞时间≥3个月的病变[1].目前,CTO已成为经皮冠状动脉介入治疗(percuta-neous coronary intervention,PCI)的难点.随着器械更新、技术成熟和研究深入,CTO-P...     

慢性冠状动脉完全闭塞病变介入治疗并发症风险评估进展

慢性冠状动脉完全闭塞病变的介入治疗(CTO-PCI)尽管临床有益,但手术并发症发生率明显高于非完全闭塞病变,影响患者预后.识别潜在的并发症风险,最大限度地降低并发症的发生,并及时地进行治疗尤为重要.本文回顾了CTO-PCI并发症风险评估的相关研究,并概述了避免并发症的策略,旨在及时准确识别CTO-PCI围手术期并发症相...     

冠状动脉旁路移植术后慢性完全闭塞病变的介入治疗现状

<正>冠状动脉旁路移植术(coronary artery bypass graft,CABG)术后的患者往往具有复杂的冠状动脉解剖情况,这些患者在CABG术前就具有严重的冠状动脉粥样硬化,而CABG术后促成冠状动脉进一步粥样硬化的进展~([1])。接近50%的CABG术后患者行冠状动脉造影时能发现慢性完全闭塞病变(chronic totalocclusion,CTO)~([2-3]),CABG术后患者经     

经皮冠状动脉介入/优化药物治疗对慢性完全闭塞病变患者长期死亡率影响的Meta分析

目的:目前对于是否开通慢性完全闭塞(CTO)病变的研究结论不一致.本研究分别基于随机对照研究及倾向性匹配研究分析,对比经皮冠状动脉介入治疗(PCI)与药物保守治疗对CTO患者长期死亡率的影响.方法:检索Pubmed,Embase,以及Cochrane Library数据库.主要终点为全因死亡.次要终点为心源性死亡,心肌...     

经皮冠状动脉介入治疗血运重建对冠状动脉慢性完全闭塞病变长期预后的影响：一项回顾性队列研究

目的 评价经皮冠状动脉介入治疗（PCI）开通慢性完全闭塞（CTO）病变对患者长期预后的影响。方法 回顾性分析首都医科大学附属北京安贞医院2015年3月至2020年1月符合入组标准并完成第一阶段随访的270例CTO病变患者。结果 纳入分析的研究对象共270例,平均年龄（57.2±10.7）岁,男212例。成功开通CTO病变患者185例,CTO病变未开通患者85例（56例患者CTO病变开通失败,29例患者初始选择优化药物治疗）。中位随访时间26.3个月。单支血管CTO病变患者153例,平均年龄（56.2±10.7）岁,男127例。成功开通CTO病变组102例,CTO病变未开通51例（CTO病变开通失败组30例,初始优化药物治疗组21例）。CTO病变开通失败组既往PCI比例高于成功开通CTO病变组（53.3%比27.5%,P=0.008）。单支血管CTO合并多支血管病变患者117例,平均年龄（58.4±10.7）岁,男85例。成功开通CTO病变组83例,CTO病变未开通34例（CTO病变开通失败组26例,初始优化药物治疗组8例）。对于单支血管CTO病变患者,Cox多因素回归分析显示,与成功开...     

直接和择期冠状动脉介入治疗对急性心肌梗死患者左心室重构和左心功能的影响

目的:探讨急性心肌梗死(AMI)患者直接及择期经皮冠状动脉介入治疗(PCI)对左心室重构和左心功能的影响。方法:对42例初次发病、发病时间在12h以内或12~24h之间的AMI患者,行直接PCI;对30例AMI患者行择期PCI。于术后2、15和30周行二维超声心动图检查并记录有关心脏事件。结果:术后2、15周直接PCI组的左心室收缩末容积指数(ESVI)、左心室舒张末容积指数(EDVI)、左心室射血分数(LVEF)和梗死区室壁运动指数(RWMI)均显著优于择期PCI组(P<0.05或P<0.01)。择期PCI组、直接PCI组15和30周ESVI、EDVI、LVEF及RWMI与2周时比均有显著改善(P<0.05,P<0.01)。至30周时,直接PCI组和择期PCI组EDVI、LVEF和RWMI差异无统计学意义,而ESVI差异有统计学意义(P<0.05)。全心室壁运动指数在2组间始终差异无统计学意义(P>0.05)。结论:直接PCI及择期PCI均可有效抑制左心室重构和改善左心室功能,但直接PCI更优于择期PCI。     

Meta‐analysis of the impact of successful chronic total occlusion percutaneous coronary intervention on left ventricular systolic function and reverse remodeling

Background

We sought to examine the impact of coronary chronic total occlusion (CTO) percutaneous coronary intervention (PCI) on left ventricular (LV) function.

Methods

We performed a systematic review and meta‐analysis of studies published between January 1980 and November 2017 on the impact of successful CTO PCI on LV function.

Results

A total of 34 observational studies including 2735 patients were included in the meta‐analysis. Over a weighted mean follow‐up of 7.9 months, successful CTO PCI was associated with an increase in LV ejection fraction by 3.8% (95%CI 3.0‐4.7, P < 0.0001, I ² = 45%). In secondary analysis of 15 studies (1248 patients) that defined CTOs as occlusions of at least 3‐month duration and reported follow‐up of at least 3‐months after the procedure, successful CTO PCI was associated with improvement in LV ejection fraction by 4.3% (95%CI [3.1, 5.6], P < 0.0001). In the 10 studies (502 patients) that reported LV end‐systolic volume, successful CTO PCI was associated with a decrease in LV end‐systolic volume by 4 mL, (95%CI ?6.0 to ?2.1, P < 0.0001, I ² = 0%). LV end‐diastolic volume was reported in 9 studies with 403 patients and did not significantly change after successful CTO PCI (?2.3 mL, 95%CI ?5.7 to 1.2 mL, P = 0.19, I ² = 0%).

Conclusions

Successful CTO PCI is associated with a statistically significant improvement in LV ejection fraction and decrease in LV end‐systolic volume, that may reflect a beneficial effect of CTO recanalization on LV remodeling. The clinical implications of these findings warrant further investigation.

     

慢性闭塞病变患者冠脉介入治疗术后1年疗效分析

目的:通过冠状动脉慢性闭塞病变(CTO)患者冠脉介入治疗(PCI)经验总结探讨开通CTO对于患者临床症状、左室功能、存活率和生活质量的影响。方法: 选择于心内科病房住院接受冠脉造影、其中至少1支冠脉主支血管为CTO并接受PCI的患者,根据PCI手术是否成功分为成功组和失败组。应用正向导丝技术处理病变。出院后1年对患者进行随访。评价的终点事件包括死亡、心肌梗死、中风、再次PCI治疗和冠状动脉旁路移植术(CABG)。对各项数据进行统计学分析。结果: 434名入选患者,CTO介入治疗成功316名,失败118名。PCI失败组患者既往接受PCI手术(P<0.01)或CABG术(P<0.01)显著高于PCI成功组,高龄和吸烟比例也显著高于PCI成功组。两组患者在高血压病、高血脂、陈旧心梗及糖尿病等病史和心功能方面没有显著差别。PCI失败组两支CTO病变以及多支血管病变比率均显著高于PCI成功组患者(均P<0.01)。术后1年两组患者在死亡、心梗、中风和再次PCI方面没有显著差异,失败组患者心绞痛发生率高(P<0.01),介入术后进行择期CABG手术比例高于成功组患者(P<0.01)。结论: 开通CTO可显著降低患者心绞痛和CABG手术率,而死亡、心梗、中风和再次PCI方面没有显著差异。     

The predictors of successful percutaneous coronary intervention in ostial left anterior descending artery chronic total occlusion

Background: Percutaneous coronary intervention (PCI) to chronic total occlusion (CTO) has become one of the treatment strategies in recent era. The ostium of the left anterior descending artery (LAD) is one of the most difficult positions for CTO revascularization. Until now, limited data has been made available for the prediction of successful ostial LAD CTO PCI. Objective: The aim of the study was to compare the differences between ostial LAD and all other CTOs and to identify the predictors of successful ostial LAD CTO PCI. Methods: This retrospective analysis included consecutive patients referred for CTO PCI between January 2001 and September 2013. Ostial LAD CTO was defined as CTO at the position whose distance between lesion and left main bifurcation was less than 1 mm. Baseline demographics, lesion characteristics, interventional procedure details, and devices were compared between the ostial LAD group and the all other CTOs group. The predictors of successful ostial LAD CTO PCI were also evaluated. Results: 621 patients who underwent CTO PCI were enrolled retrospectively to this study. A total of 70 patients of ostial LAD CTO were compared with 551 patients of all other CTOs group in this study. Ostial LAD CTO was found to have more bridging and better collaterals than all other CTOs. Procedure time, fluoroscopic time, contrast volumes, the use of contralateral injection, and the use of the retrograde approach were significantly greater in the ostial LAD CTO group. The ostial LAD CTO group also had significantly higher J‐CTO scores (2.7 ± 0.8 vs. 2.2 ± 1.1, P = 0.011) and higher Syntax Scores (28.3 ± 6.5 vs. 20.9 ± 9.7, P < 0.001). A slightly lower final success rate, but statistically non‐significant, was observed in the ostial LAD CTO group (80.0% vs. 81.9%, P = 0.706). Univariate and multivariate logistic regression revealed that without antegrade failure and with retrograde success were predictors of the success of ostial LAD CTO PCI. Syntax Score was also capable of predicting the ostial LAD CTO PCI outcome. J‐CTO score was not found to be associated with final success for ostial LAD CTO patients. Conclusions: Ostial LAD CTO resulted in higher lesion complexity in J‐CTO scores and Syntax Scores. Ostial LAD CTO PCI had a slightly lower final success rate than that of all other CTOs PCI with longer procedure duration, fluoroscopic time and larger contrast volume. Without antegrade failure, with retrograde success, and lower Syntax Score were found to predict the success of ostial LAD CTO PCI. © 2014 Wiley Periodicals, Inc.     

Recovery of left ventricular function after percutaneous revascularization of a left main chronic total occlusion

Surgical revascularization of left main and/or three‐vessel coronary artery disease (CAD) is associated with improved survival in patients with left ventricular dysfunction when compared to medical therapy and can result in improved left ventricular ejection fraction (LVEF) [ 1 ]. Multivessel percutaneous coronary intervention (PCI) is equivalent to surgery regarding short and intermediate term mortality, and left main PCI has emerged as a safe and effective alternate to surgical revascularization [ 2 ]. However, outcomes of unprotected left main PCI in patients with severely depressed LVEF have not been examined. We report a patient with left main chronic total occlusion, multivessel CAD, and dilated cardiomyopathy, in whom complete revascularization via PCI resulted in decreased left ventricular size and improved LVEF. © 2012 Wiley Periodicals, Inc.     

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.     

Contrast modulation in chronic total occlusion percutaneous coronary intervention

The intraplaque injection of contrast media in the recanalization of coronary chronic total occlusions (CTO) has witnessed a dynamic journey since its initial formulation. Contrast‐guided subintimal tracking and re‐entry (STAR) was the first contrast modulation technique for CTO percutaneous coronary intervention (PCI). With this technique, a forceful injection of a large volume of contrast (3–4 mL) was performed in order to achieve hydraulic recanalization of the vessel. This approach was associated with extensive vessel injury and unpredictable true lumen re‐entry, which were in turn linked to high rates of restenosis on follow‐up. In the subsequent iteration, called the “microchannel technique”, a smaller amount of contrast media (1 mL) was gently injected inside the plaque to modify its compliance by softening and recruiting loose tissue, which facilitated subsequent true‐to‐true lumen crossing with a polymer‐jacketed wire along paths of least resistance. The microchannel technique has later evolved into what is currently known as the “Carlino technique”, where a minimal volume of contrast media (<0.5 mL) is gently injected inside the occlusion, with the goal of modifying plaque compliance to facilitate guidewire and microcatheter advancement through a fibrocalcific plaque. The Carlino technique is now widely utilized to allow negotiation of difficult‐to‐cross occlusions, particularly by the “hybrid operators”, with high success rates and low incidence of complications. The purpose of this article is to provide a historical perspective on the use of contrast modulation in CTO PCI, its pathophysiological basis, as well as technical recommendations on how and when to perform these maneuvers.