慢性完全闭塞之个人观点

Paul Hsien-Li Kao, MD Assistant Professor National Taiwan University Medical School & Hospital,Chronic Total Occlusion Personal Thoughts,Last frontiers for PCI,With the advancement in techniques and equipments, indications of percutaneous coronary intervention (PCI) have been expanded to almost all complex lesion subsets in all high risk patients populations Left main (LM) coronary artery and chronic total occlusion (CTO) remain the last frontiers for PCI,CTO: the Achilles heel of PCI,CTO is the most challenging lesion subset in PCI Success rate 50-70% The most frequent reason of failure is unsuccessful wire crossing Success rate depends on the patient selection criteria , equipment availability, as well as the interventional technique Restenosis rate after CTO recanalization is high 50-70% after balloon only Significant re-stenosis and re-occlusion rates despite BMS,Why should we open a CTO?,Improves perfusion to viable tissue with ischemia Improves perfusion to hibernation tissue with depressed contractile function Provide and increase collateral perfusion to other viable myocardial territory Avoid or defer CABG, making less invasive hybrid procedure possible Improves clinical symptoms and long-term survival,TOAST-GISE,376 patients/390 CTO attempted in 29 Italian centers from 1999-2000 Technical success rate 77.3% Only predictor for 12 month MACE free survival is success of CTO PCI,Olivari et at. JACC 03,Definition and indication,Occlusion Interruption of lumen for a certain distance TIMI 0 or TIMI 1 (functional occlusion) flow Chronic No ACS within 3 months, or documented 3 months with prior angiogram Collaterals Gr 2 should be present Indication for PCI Angina Silent or angina-equivalent symptoms with ischemia shown in non-invasive studies such as thallium 201 scan,Essentials for CTO PCI,Bi-plane cine with good quality fluoroscopy Selections of devices 6-8F GC of various curve Micro-catheter (personal favorite is Excelsior) CTO GW (personal favorite is Conquest family) OTW 1.25-1.5 BC Tornus, rotablator Hydrophilic GW for retrograde approach (personal favorite is Fielder) Cardiac echo and pericardial tapping kit just in case,Personal CTO experience,Routine attempts for CTO started in 1998, but low success rate until 2002 when dedicated CTO devices were available An increase in CTO PCI case volume since 2004, with more interest and thoughts on the anatomy and techniques MDCT was introduced in 2005 Tornus was available in 2005 Retrograde approach was introduced in 2006 Now roughly 100 CTO PCI per year, 25% of the total personal PCI volume,Patient cohort,Single operator registry from Jun 05 to Oct 07 Totally 244 attempted CTO lesions (23% of the total 1060 PCIs in the same period) in 212 patients Patients age 62.7 7.4 yrs Ad-hoc procedure in 167 lesions (69%),Demographics,Set-up,Femoral approach is favored Careful diagnostic biplane imaging with multiple angles Contra-lateral injection is very helpful (80% of lesions) Evaluate the angiogram frame by frame to understand stump morphology, imaginary tract of the missing segment, and distal vessel direction Choose a GC with good support EBU/XB/Voda/JCL for LAD XB/VL/AL/KL for LCX AL/FR for RCA,Antegrade approach,Intermediate GW leading MC to the entry and exchange GW Penetrate proximal cap with Conquest pro Side branch occlusion technique IVUS in side branch Parallel GW or see-saw GW advancement Avoid excessive drilling Intentional advance Penetrate distal cap and confirm GW position,RCA CTO 3y,Parallel wire crossing,Pre and post,Retrograde approach,Level 1 MC advanced over Fielder through collateral channel (with channel dilatation) Exchange GW and kissing GW Level 2 BC advanced over retro GW to dilate CTO Level 3 (CART) False lumen dilatation to facilitate GW re-entry from the other direction Level 4 (back-end) MC advanced into ante GC and GW exchanged to 300GW Back-end dilatation followed by reversed withdrawal,LAD CTO 4y retrograde,Exchanged to Conquest pro,GW kissed and final,Device crossing,1.25 or 1.5 lubricity BC with low profile When BC crossing difficult Side-branch anchor technique Buddy wire RA if wire can be exchanged to rota-wire Mother-and-child technique Tornus Wire trapping by balloon from the other direction DES unless contra-indicated,Angiographic data,Procedure results,According to vessel,Retrograde channel finding,The most obvious channel is not always the best channel Avoid epicardial ones Look for straight shot Use hydrophilic guide wire (GW) with optimal shaft support and extension option Always use micro-catheter (MC) to support GW,LAD ostial CTO,Candidate channels,Retrograde channel wiring,Dilatation and MC advance,My way of retrograde CTO crossing,Try hydrophilic GW for less than 5 minutes and avoid over-steering Try to advance the MC gently When MC cannot be advanced Extend GW and remove MC Advance 1.25 OTW balloon for channel dilatation Exchange the hydrophilic GW to CTO GW inside MC Bi-plane imaging for retrograde CTO crossing,Retrograde CTO crossed,Next step options,Antegrade wire advancement? Balloon dilatation from the retrograde wire? “Level 4” technique Advance GW and MC into antegrade GC Withdraw retrograde GW Advance 300cm GW inside MC into antegrade GC until out of Touhy-Borst Use the tip of 300cm GW as the back-end for antegrade ballooning,Retro GW/MC into ante GC,Remove MC and back-end balloon,After back-end dilatation,What next?,Finish the case with back-end stenting? Lesion distal to the take-off of the retro channel? Injury by the 300cm GW stiff end if withdrawn from ante GC! Advance another floppy GW from ante GC across CTO? May be difficult, and with increased risk of vessel rupture! Back-end advancement of MC from ante GC over 300cm GW into retro GC (MC reversal) Remove 300