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Tim Kinnaird Richard Anderson Sean Gallagher James Cockburn Alex Sirker Peter Ludman Mark de Belder Samuel Copt James Nolan Azfar Zaman Mamas Mamas 《JACC: Cardiovascular Interventions》2018,11(5):482-492
Objectives
Using the British Cardiovascular Intervention Society percutaneous coronary intervention (PCI) database, access site choice and outcomes of patients undergoing PCI with previous coronary artery bypass grafting (CABG) were studied.Background
Given the influence of access site on outcomes, use of radial access in PCI-CABG warrants further investigation.Methods
Data were analyzed from 58,870 PCI-CABG procedures performed between 2005 and 2014. Multivariate logistic regression was used to identify predictors of access site choice and its association with outcomes.Results
The number of PCI-CABG cases and the percentage of total PCI increased significantly during the study period. Femoral artery (FA) utilization fell from 90.8% in 2005 to 57.6% in 2014 (p < 0.001), with no differences in the rate of change of left versus right radial use. In contemporary study years (2012 to 2014), female sex, acute coronary syndrome presentation, chronic total occlusion intervention, and lower operator volume were independently associated with FA access. Length of stay was shortened in the radial cohort. Unadjusted outcomes including an access site complication (1.10% vs. 0.30%; p < 0.001), blood transfusion (0.20% vs. 0.04%; p < 0.001), major bleeding (1.30% vs. 0.40%; p < 0.001), and in-hospital death (1.10% vs. 0.60%; p = 0.001) were more likely to occur with FA access compared with radial access. After adjustment, although arterial complications, transfusion, and major bleeding remained more common with FA use, short- and longer-term mortality and major adverse cardiac event rates were similar.Conclusions
In contemporary practice, FA access remains predominant during PCI-CABG with case complexity associated with it use. FA use was associated with longer length of stay, and higher rates of vascular complications, major bleeding, and transfusion. 相似文献93.
《JACC: Cardiovascular Interventions》2015,8(2):257-267
ObjectivesThis study sought to establish a coronary computed tomography angiography prediction rule for grading chronic total occlusion (CTO) difficulty for percutaneous coronary intervention (PCI).BackgroundThe uncertainty of procedural outcome remains the strongest barrier to PCI in CTO.MethodsData from 4 centers involving 240 consecutive CTO lesions with pre-procedural coronary computed tomography angiography were analyzed. Successful guidewire (GW) crossing ≤30 min was set as an endpoint to eliminate operator bias. The CT-RECTOR (Computed Tomography Registry of Chronic Total Occlusion Revascularization) score was developed by assigning 1 point for each independent predictor, and then summing all points accrued. Continuous distribution of scores was used to stratify CTO into 4 difficulty groups: easy (score 0); intermediate (score 1); difficult (score 2); and very difficult (score ≥3). Discriminatory performance was tested by 10-fold cross-validation and compared with the angiographic J-CTO (Multicenter CTO Registry of Japan) score.ResultsStudy endpoint was achieved in 55% of cases. Multivariable analysis yielded multiple occlusions, blunt stump, severe calcification, bending, duration of CTO ≥12 months, and previously failed PCI as independent predictors for GW crossing. The probability of successful GW crossing ≤30 min for each group (from easy to very difficult) was 95%, 88%, 57%, and 22%, respectively. Areas under receiver-operator characteristic curves for the CT-RECTOR and J-CTO scores were 0.83 and 0.71, respectively (p < 0.001). Both the original model fit and 10-fold cross-validation correctly classified 77.3% of lesions.ConclusionsThe CT-RECTOR score represents a simple and accurate noninvasive tool for predicting time-efficient GW crossing that may aid in grading CTO difficulty before PCI. (Computed Tomography Angiography Prediction Score for Percutaneous Revascularization for Chronic Total Occlusions [CT-RECTOR]; NCT02022878) 相似文献
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Rodrigo Estevez-Loureiro Matteo Ghione Kadriye Kilickesmez Pilar Agudo Alistair Lindsay Carlo Di Mario 《Current Cardiology Reviews》2014,10(2):120-126
Non invasive coronary angiography with multislice computed tomography has exquisite sensitivity to detect
calcium and even the faintest late contrast filling of the distal vessel. Calcium burden and occlusion length are still valuable
markers of duration, complexity and success of the recanalisation procedure. The ability to visualise the vessel also in
the occluded segment, especially if calcified, can also help the operator to understand where to pierce the proximal cap in
stumpless occlusions and to predict unusual courses, especially in very tortuous arteries. Imaging side by side CT images
and angiography during the recanalisation procedure is an established practice in many active CTO laboratories and algorithms
for co-registration are designed to overcome the challenges of systo-diastolic and respiratory motion. Intravascular
ultrasound is used in almost all cases by the experienced Japanese CTO operators but most of the times its main use is a
better identification of the diseased segment after predilatation to ensure complete stent cover and appropriate stent expansion,
an application similar to other complex non occlusive lesions. The specificity of IVUS during CTO recanalisation is
the identification of the vessel path in stumpless occlusions and the guidance of wire reentry especially during reverse
Controlled Retrograde Anterograde Tracking. Optical coherence tomography has limitations in the setting of CTO recanalisation
because of the need of forceful contrast flushing to clear blood, contraindicated in the presence of anterograde
dissections, and the limited penetration. The variability in the use of both non-invasive and invasive imaging during CTO
recanalisation is immense, going from more than 90% in Japan to less than 20% in Europe and intermediate penetration in
the USA. Probably the explanation is almost only in availability and cost because all countries see a progressive increase
of use suggesting that these methods are becoming an established tool for guidance of CTO recanalisation. 相似文献
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Kambis Mashayekhi Thomas G. Nührenberg Aurel Toma Michael Gick Miroslaw Ferenc Willibald Hochholzer Thomas Comberg Jürgen Rothe Christian M. Valina Nikolaus Löffelhardt Mohammed Ayoub Min Zhao Johannes Bremicker Nikolaus Jander Jan Minners Philipp Ruile Michael Behnes Ibrahim Akin Heinz Joachim Büttner 《JACC: Cardiovascular Interventions》2018,11(19):1982-1991
Objectives
The aim of this study was to investigate whether percutaneous coronary intervention (PCI) of chronic total occlusions (CTOs) improves left ventricular function.Background
The benefit of PCI in CTOs is still controversial.Methods
Patients with CTOs who were candidates for PCI were eligible for the study and were randomized to PCI or no PCI of CTO. Relevant coexisting non-CTO lesions were treated as indicated. Patients underwent cardiac magnetic resonance imaging at baseline and at 6 months. The primary endpoint was the change in segmental wall thickening (SWT) in the CTO territory. Secondary endpoints were improvement of regional wall motion and changes in left ventricular volumes and ejection fraction. Furthermore, major adverse coronary events after 12 months were assessed.Results
The CTO PCI group comprised 101 patients and the no CTO PCI group 104 patients. The change in SWT did not differ between the CTO PCI (4.1% [interquartile range: 14.6 to 19.3]) and no CTO PCI (6.0% [interquartile range: 8.6 to 6.0]) groups (p = 0.57). Similar results were obtained for other indexes of regional and global left ventricular function. Subgroup analysis revealed that only in patients without major non-CTO lesions (basal SYNTAX [Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery] score ≤13) CTO PCI was associated with larger improvement in SWT than no CTO PCI (p for interaction = 0.002). Driven by repeat intervention, major adverse coronary event rates at 12 months were significantly lower in the CTO PCI group (16.3% vs. 5.9%; p = 0.02).Conclusions
No benefit was seen for CTO PCI in terms of the primary endpoint, SWT, or other indexes of left ventricular function. CTO PCI resulted in clinical benefit over no CTO PCI, as evidenced by reduced major adverse coronary event rates at 12 months. 相似文献96.
Thomas A. Meijers Adel Aminian Marleen van Wely Koen Teeuwen Thomas Schmitz Maurits T. Dirksen Sudhir Rathore René J. van der Schaaf Paul Knaapen Joseph Dens Juan F. Iglesias Pierfrancesco Agostoni Vincent Roolvink Renicus S. Hermanides Niels van Royen Maarten A.H. van Leeuwen 《JACC: Cardiovascular Interventions》2021,14(12):1293-1303
ObjectivesThe aim of this study was to investigate whether transradial (TR) percutaneous coronary intervention (PCI) is superior to transfemoral (TF) PCI in complex coronary lesions with large-bore guiding catheters with respect to clinically relevant access site–related bleeding or vascular complications.BackgroundThe femoral artery is currently the most applied access site for PCI of complex coronary lesions, especially when large-bore guiding catheters are required. With downsizing of TR equipment, TR PCI may be increasingly applied in these patients and might be a safer alternative compared with the TF approach.MethodsAn international prospective multicenter trial was conducted, randomizing 388 patients with planned PCI for complex coronary lesions, including chronic total occlusion, left main, heavy calcification, or complex bifurcation, to either 7-F TR access (TRA) or 7-F TF access (TFA). The primary endpoint was defined as access site–related clinically significant bleeding or vascular complications requiring intervention at discharge. The secondary endpoint was procedural success.ResultsThe primary endpoint event rate was 3.6% for TRA and 19.1% for TFA (p < 0.001). The crossover rate from radial to femoral access was 3.6% and from femoral to radial access was 2.6% (p = 0.558). The procedural success rate was 89.2% for TFA and 86.0% for TRA (p = 0.285). There was no difference between TFA and TRA with regard to procedural duration, contrast volume, or radiation dose.ConclusionsIn patients undergoing PCI of complex coronary lesions with large-bore access, radial compared with femoral access is associated with a significant reduction in clinically relevant access-site bleeding or vascular complications, without affecting procedural success. (Complex Large-Bore Radial Percutaneous Coronary Intervention [PCI] Trial [Color]; NCT03846752) 相似文献
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Retrograde puncture via patent pedal vessels can be attempted in failed antegrade approach for infrapopliteal long chronic total occlusion. However in cases where the pedal vessels are unable to be visualized via duplex ultrasonography or fluoroscopy an open approach offers an additional option to a vascular surgeon for successful recanalization. Our case report highlights 3 cases where successful hybrid open retrograde approach was able to achieve recanalization of long chronic total occlusion.Presentation of casesThe three cases in our series presented with critical limb ischaemia. All three cases had undergone duplex imaging of the affected arterial system. As the antegrade approach to cross the lesion failed a retrograde approach was attempted in all 3 cases. However when the usual modality of retrograde puncture via the use of ultrasound or fluoroscopy failed we proceeded with an open approach.DiscussionRetrograde approach usually offers a better chance of successfully crossing a chronic total occlusion lesion. However puncturing a distal vessel successfully and traversing a catheter or guidewire across proves to be a challenge. An open approach offers an additional pathway for puncturing the target vessel when duplex imaging or fluoroscopic guidance fails.ConclusionOpen approach is usually attempted as a last resort by many endovascular surgeons. However procedural time, contrast and radiation usage could have been cut short in cases where the distal target vessels pose a technical challenge for approach via a percutaneous method. 相似文献
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Ostial right coronary chronic total occlusion: Transesophageal echocardiographic guidance for retrograde aortic re‐entry
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Frank E. Corrigan MD III Dimitrios Karmpaliotis MD Habib Samady MD Stamatios Lerakis MD 《Catheterization and cardiovascular interventions》2018,91(6):1070-1073
As antegrade options are limited, intervention upon the ostial right coronary artery (RCA) chronic total occlusion (CTO) warrants a retrograde approach. Landmarks for an aggressive approach are concerning as passage of stiff guidewires or electrocautery near the RCA ostium may result in wire passage into structures other than the aorta. We report the first use of transesophageal echocardiography (TEE) to assist retrograde passage of a guidewire into the aorta. For the ostial RCA CTO, TEE guidance may be considered to assist retrograde passage of aggressive guidewires into the aorta. 相似文献