慢性完全闭塞之个人观点

1、慢性完全闭塞之个人观点Last frontiers for PCIWith 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 populationsLeft main (LM) coronary artery and chronic total occlusion (CTO) re

2、main the last frontiers for PCICTO: the Achilles heel of PCICTO is the most challenging lesion subset in PCISuccess rate 50-70%The most frequent reason of failure is unsuccessful wire crossingSuccess rate depends on the patient selection criteria , equipment availability, as well as the intervention

3、al techniqueRestenosis rate after CTO recanalization is high50-70% after balloon onlySignificant re-stenosis and re-occlusion rates despite BMSWhy should we open a CTO?Improves perfusion to viable tissue with ischemiaImproves perfusion to hibernation tissue with depressed contractile functionProvide

4、 and increase collateral perfusion to other viable myocardial territoryAvoid or defer CABG, making less invasive hybrid procedure possibleImproves clinical symptoms and long-term survivalTOAST-GISESuccess (N=286)Failure (N=83)P-valueAll death3 (1.0%)3 (3.6%)0.13Cardiac death1 (0.3%)3 (3.6%)0.03Non-f

5、atal QMI1 (0.3%-Non-fatal NQMI1 (0.3%)3 (3.6%)0.03Cardiac death/MI3 (1.0%)6 (7.2%)0.005CABG7 (2.4%)13 (15.7%)3 months with prior angiogramCollaterals Gr 2 should be presentIndication for PCIAnginaSilent or angina-equivalent symptoms with ischemia shown in non-invasive studies such as thallium 201 sc

6、anEssentials for CTO PCIBi-plane cine with good quality fluoroscopySelections of devices6-8F GC of various curveMicro-catheter (personal favorite is Excelsior) CTO GW (personal favorite is Conquest family)OTW 1.25-1.5 BCTornus, rotablatorHydrophilic GW for retrograde approach (personal favorite is F

7、ielder)Cardiac echo and pericardial tapping kit just in casePersonal CTO experienceRoutine attempts for CTO started in 1998, but low success rate until 2002 when dedicated CTO devices were availableAn increase in CTO PCI case volume since 2004, with more interest and thoughts on the anatomy and tech

8、niquesMDCT was introduced in 2005Tornus was available in 2005Retrograde approach was introduced in 2006Now roughly 100 CTO PCI per year, 25% of the total personal PCI volumePatient cohortSingle operator registry from Jun 05 to Oct 07Totally 244 attempted CTO lesions (23% of the total 1060 PCIs in th

9、e same period) in 212 patientsPatients age 62.7 7.4 yrsAd-hoc procedure in 167 lesions (69%)DemographicsN (%)Male153 (72)HTN165 (78)DM79 (37)HLP110 (52)Smoker104 (49)CTO location LAD102 (42) LCX53 (22) RCA81 (33) LM3 (1) SVG5 (2)Set-upFemoral approach is favoredCareful diagnostic biplane imaging wit

10、h multiple anglesContra-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 directionChoose a GC with good supportEBU/XB/Voda/JCL for LADXB/VL/AL/KL for LCXAL/FR for RCAAnteg

11、rade approachIntermediate GW leading MC to the entry and exchange GWPenetrate proximal cap with Conquest proSide branch occlusion techniqueIVUS in side branchParallel GW or see-saw GW advancementAvoid excessive drillingIntentional advance Penetrate distal cap and confirm GW positionRCA CTO 3yParalle

12、l wire crossingPre and postRetrograde approachLevel 1MC advanced over Fielder through collateral channel (with channel dilatation)Exchange GW and kissing GWLevel 2BC advanced over retro GW to dilate CTOLevel 3 (CART) False lumen dilatation to facilitate GW re-entry from the other directionLevel 4 (b

13、ack-end)MC advanced into ante GC and GW exchanged to 300GWBack-end dilatation followed by reversed withdrawalLAD CTO 4y retrogradeExchanged to Conquest proGW kissed and finalDevice crossing1.25 or 1.5 lubricity BC with low profileWhen BC crossing difficultSide-branch anchor techniqueBuddy wireRA if

14、wire can be exchanged to rota-wire Mother-and-child techniqueTornusWire trapping by balloon from the other directionDES unless contra-indicatedAngiographic dataReference diameter (mm)2.7 0.9Occlusion length (mm)25.3 8.4Final balloon-to-artery ratio1.1 0.3Residual stenosis (%)11 9Guide wires used per

15、 lesion2.4Balloon used per lesion1.9Fluoroscopic time (min)42 38Total procedure time (min)100 87Contrast volume (ml)252 92Procedure resultsN%Wire crossing success206/24492 primary wire2711 parallel/seesaw wire8133 retrograde5123Device crossing success197/20696Stenting192/19797Complication42 perforat

16、ion with tanponade21 CKMB 5x 42According to vesselLADLCXRCAotherN10253818Wire cross (%)95 (93)42 (79)63 (77)6 (75)Device cross (%)92 (97)34 (82)61(97)6 (100)Complication (%)2 (2)1 (2)1 (1)0 (0)Overall success (%)90 (88)33 (62)60(74)6 (75)Retrograde channel findingThe most obvious channel is not alwa

17、ys the best channelAvoid epicardial onesLook for straight shotUse hydrophilic guide wire (GW) with optimal shaft support and extension optionAlways use micro-catheter (MC) to support GWLAD ostial CTOCandidate channelsRetrograde channel wiringDilatation and MC advanceMy way of retrograde CTO crossing

18、Try hydrophilic GW for less than 5 minutes and avoid over-steeringTry to advance the MC gentlyWhen MC cannot be advancedExtend GW and remove MCAdvance 1.25 OTW balloon for channel dilatationExchange the hydrophilic GW to CTO GW inside MCBi-plane imaging for retrograde CTO crossingRetrograde CTO cros

19、sedNext step optionsAntegrade wire advancement?Balloon dilatation from the retrograde wire?“Level 4” techniqueAdvance GW and MC into antegrade GCWithdraw retrograde GWAdvance 300cm GW inside MC into antegrade GC until out of Touhy-BorstUse the tip of 300cm GW as the back-end for antegrade ballooning

20、Retro GW/MC into ante GCRemove MC and back-end balloonAfter back-end dilatationWhat 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 300cm GW from the retro GCWithdraw MC until proximal to the channel take-offAdvance another floppy GW inside MC into distal vessel300cm GC r