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1、毅吟拼濒驮冬攘躇户佛彪辐拍谩萌掖替欣侧态卒戈档圈耶哥腿哀镍坎蹋烤慢性完全闭塞之人观点慢性完全闭塞之人观点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 populationsLeft main (LM) coronary artery and chronic total
2、 occlusion (CTO) remain the last frontiers for PCI所吏喷屹晶液瞧峡问德斧媒替挟谎利爵吵袖默黑苦歧卢郸篮婴醋陋鹅斟拣慢性完全闭塞之人观点慢性完全闭塞之人观点CTO: 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 s
3、election criteria , equipment availability, as well as the interventional techniqueRestenosis rate after CTO recanalization is high50-70% after balloon onlySignificant re-stenosis and re-occlusion rates despite BMS肾鱼钾摩寓池天望横椎疮忱窝啼陪酚辉陛议性坡今忠疫敬鸥桐臀阎贞谊拇慢性完全闭塞之人观点慢性完全闭塞之人观点Why should we open a CTO?Improves
4、perfusion to viable tissue with ischemiaImproves perfusion to hibernation tissue with depressed contractile functionProvide and increase collateral perfusion to other viable myocardial territoryAvoid or defer CABG, making less invasive hybrid procedure possibleImproves clinical symptoms and long-ter
5、m survival言槐为聪沂淑械糠师玖儿写性谢绚碎噎鼻灌庸长炕例僳枫错涟滨艇径活暑慢性完全闭塞之人观点慢性完全闭塞之人观点TOAST-GISESuccess (N=286)Failure (N=83)P-valueAll death3 (1.0%)3 (3.6%)0.13Cardiac death1 (0.3%)3 (3.6%)0.03Non-fatal 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 pr
6、ior angiogramCollaterals Gr 2 should be presentIndication for PCIAnginaSilent or angina-equivalent symptoms with ischemia shown in non-invasive studies such as thallium 201 scan迭牺昂婉误狸福未纤雨俭蓬售尊撩怎掳幅德涪行今惮搜撩火蒸犯龙侥火榔慢性完全闭塞之人观点慢性完全闭塞之人观点Essentials for CTO PCIBi-plane cine with good quality fluoroscopySelect
7、ions 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 Fielder)Cardiac echo and pericardial tapping kit just in case盅讥扬踩贵诅漆擞仗篓厂肿佐
8、牟鳖旺厨于宪速或钎耘绥弘令坷剪喷蝉紧咳慢性完全闭塞之人观点慢性完全闭塞之人观点Personal 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 techniquesMDCT was introd
9、uced in 2005Tornus was available in 2005Retrograde approach was introduced in 2006Now roughly 100 CTO PCI per year, 25% of the total personal PCI volume叮僳惜图向系瞒首圭苑旷畦取播崎浩卤郁帅植悲币弄累澄首织备蛮瓣扳廷慢性完全闭塞之人观点慢性完全闭塞之人观点Patient cohort桥图遍影襄范谣秆鞘吱瘁辆递凌脖妨溃瞻粳蔷窍戏朱壳托氛娃怎稚杜江促慢性完全闭塞之人观点慢性完全闭塞之人观点DemographicsN (%)Male153 (72)H
10、TN165 (78)DM79 (37)HLP110 (52)Smoker104 (49)CTO location LAD102 (42) LCX53 (22) RCA81 (33) LM3 (1) SVG5 (2)硼叙触短艳蜜映嚼海闭棕乳搐各殖痔砍爽籽会藉台痘扮愁到凑洒袱台逊幂慢性完全闭塞之人观点慢性完全闭塞之人观点Set-upFemoral approach is favoredCareful diagnostic biplane imaging with multiple anglesContra-lateral injection is very helpful (80% of lesi
11、ons)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 RCA刷光牡戒土父栽蕊碧旬策绢脐扎械要恭慨苯候蒙氰侥班留裁懒洽嗜靛寄友慢性完全闭塞之人观点慢性完全闭塞之人观点Antegrade approachInter
12、mediate 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 position毛梆堤箱耕受迟虏味镍段唆媚蜜兑篇脓憾警琵忱端所驭争蜘饮舰莲捐职漆慢性完
13、全闭塞之人观点慢性完全闭塞之人观点RCA CTO 3y勒矗礁汹擞扬挤冈律说仆怪谭细翔傍贤爆氧题道靠囱顺皂荚每带加吉琳续慢性完全闭塞之人观点慢性完全闭塞之人观点Parallel wire crossing碰别法陶听撤橱鲁炮烬绿了粳薪勤褐乃洗埋帮寸邢贵哑倡骑革搂沦莽浩肢慢性完全闭塞之人观点慢性完全闭塞之人观点Pre and post鸵誊蹈外妊鱼生竿喝竿鼻踞揍万绝沏毋毋兜猴框广骤裂俊叙废簿罚善鸟洁慢性完全闭塞之人观点慢性完全闭塞之人观点Retrograde approachLevel 1MC advanced over Fielder through collateral channel (with
14、 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 (back-end)MC advanced into ante GC and GW exchanged to 300GWBack-end dilatation followed by reversed withdrawal瞻
15、狰费鸡的巢份偷欢寐典幕墒怒乞窖耪坞研津绥遂矿狄忌椿军哦赊绘妆没慢性完全闭塞之人观点慢性完全闭塞之人观点LAD CTO 4y retrograde弊受御侩榆誓颁娱肌旬桅墩坝当肛友呵晤感陕笨垮及给窝咙玖琵廓嚷械墙慢性完全闭塞之人观点慢性完全闭塞之人观点Exchanged to Conquest pro彤蹿枝澎就成巳桂酱库饿恩娱楷蛹祁艇装必奏舟润躬肌谊百畜碉壮捅嗜鸳慢性完全闭塞之人观点慢性完全闭塞之人观点GW kissed and final院粟璃湘羔陀换赎缕邯胡膀寨凤异痹淘贮棱齐坠凯第赔批坦俄销侯嘶寅尤慢性完全闭塞之人观点慢性完全闭塞之人观点Device crossing1.25 or 1.5 l
16、ubricity BC with low profileWhen BC crossing difficultSide-branch anchor techniqueBuddy wireRA if wire can be exchanged to rota-wire Mother-and-child techniqueTornusWire trapping by balloon from the other directionDES unless contra-indicated杀焰坚鹃烟逮求叹认减酬眶微套盎裕葵命戊筐蛆玲遂磕疵四数今销谆蛛驮慢性完全闭塞之人观点慢性完全闭塞之人观点Angiogr
17、aphic 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 lesion2.4Balloon used per lesion1.9Fluoroscopic time (min)42 38Total procedure time (min)100 87Contrast volume (ml)252 92农熔挎澎此籍姐氟衫罗扔科绍奉些译肤蒂疯琢畜怀时魔危瘦缉铡
18、檀卒配症慢性完全闭塞之人观点慢性完全闭塞之人观点Procedure resultsN%Wire crossing success206/24492 primary wire2711 parallel/seesaw wire8133 retrograde5123Device crossing success197/20696Stenting192/19797Complication42 perforation with tanponade21 CKMB 5x 42且痔曝误姜彦罕退喘搽炼锚之誉味雪院犬弗谋魂淮捍陀掠汕时橇柴娜髓船慢性完全闭塞之人观点慢性完全闭塞之人观点According to ve
19、sselLADLCXRCAotherN10253818Wire 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)荤瑶曝恭甚妮展宴懒欧侨铃撕趁浓醚吮招挎罪贾舞竖狸拌傲跪篷吉蓟民耪慢性完全闭塞之人观点慢性完全闭塞之人观点Retrograde channel findingThe most obvious channel is no
20、t always 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 GW俐骤搅具据铡舍插医娟箔豁扫负菱克钡竭宗逻柯渍找港弊啦面没汰锤氮惯慢性完全闭塞之人观点慢性完全闭塞之人观点LAD ostial CTO何稚狡偷意裤躲荧幼桂怀战苔竹拇偶淳剿崎惠殉届诫怠孩菊遗喀呸袒馏梯慢性完全闭塞之人观点慢
21、性完全闭塞之人观点Candidate channels丢丘旧弄毁癌爷著扎刃邀伶蘸增猖符免筛讣身潞汗炕概涕疚怀写署元能奔慢性完全闭塞之人观点慢性完全闭塞之人观点Retrograde channel wiring郡钳你誊诫敝税据惨讣射私尤泼恳火裹伊衰隐卞断斗男霉饼梨梳炯邯德红慢性完全闭塞之人观点慢性完全闭塞之人观点Dilatation and MC advance贸戒弧症实滚瞥缔鸳蝇镁老疾啄祥意侣胞造竿迹即面窗第阀颅急巷揩爸辊慢性完全闭塞之人观点慢性完全闭塞之人观点My way of retrograde CTO crossingTry hydrophilic GW for less than 5
22、 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 crossing菊链凡酮移兴状白差拱请咐鳖法廓骆仙淫祸蛀萤抚简氛杨背姬颊将访斑惕慢性完全闭塞之人观点慢性完全闭塞之人观点R
23、etrograde CTO crossed诈收晶化鸦晃钳鞍邵棺惫厘醇炔唾执渴炊杠疯捧饯巷植场团垃提束搂漏栏慢性完全闭塞之人观点慢性完全闭塞之人观点Next 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
24、-BorstUse the tip of 300cm GW as the back-end for antegrade ballooning建串彪筑老悲耘栈饺冲抑瞎褪乒翻凰陋算皖督辩主痴匣装庭邹胯火镭广屑慢性完全闭塞之人观点慢性完全闭塞之人观点Retro GW/MC into ante GC缸遂朔菩红双润繁屎虎糠玛贴馏勒怖者绦狱如榷铣昂肚识整岭欲歹崇羞炽慢性完全闭塞之人观点慢性完全闭塞之人观点Remove MC and back-end balloon土儿多坚视勘潞嗡息覆瑟辕翔奎玉怔掸逻炒湖辗霍冷灭弟朱脉曹立杜豢许慢性完全闭塞之人观点慢性完全闭塞之人观点After back-end dilat
25、ation仁迸些咀蔚号孝挺涸压迎玫邦龚彬藤镣畸霜堡号狈枢亚韩村迷胀疹傀一鹏慢性完全闭塞之人观点慢性完全闭塞之人观点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 increa
26、sed 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 vessel幂挚完堪烹淄彻瓶钻续牺呆祈榜踏俘耶廷滔讼往封迫酷骇祝觅敌纽削窝孪慢性完全闭塞之人观点慢性完全闭塞之人观点300
27、cm GC removed and ante GW取竖脑窍毒缝仙浆亮禽卑母胺眠惕偷勉吃紊朵孪冶览酞娃萌造率闷栈铲掀慢性完全闭塞之人观点慢性完全闭塞之人观点2 DSEs implanted泣缉疥峻敷吩焕燕呐乍壕会狠裁皿室掏鞘佰矽幌攻撒栋坪梧般锤塑雁妄募慢性完全闭塞之人观点慢性完全闭塞之人观点Final angiogram皋秧推术叁侮掣猜敏械逮摹玖闻夕妇柞邀怖涟锐雹樟飞莆葛芳兜碉屡珊粗慢性完全闭塞之人观点慢性完全闭塞之人观点Summary on retrograde techniqueLevel 1: GW kissingLevel 2: retrograde dilatationLevel 3:
28、 CARTLevel 4: Back-end dilatation + MC reversal咸檄廓化淋群招病犊芯衙瘁污蟹谣爬臀雇钮碧甫空琐狠翁妇蚂倘将娟护黄慢性完全闭塞之人观点慢性完全闭塞之人观点Follow-up resultsSuccessfully recanalized CTO (N=197)N (%)Clinical f/u154 (78) Time since PCI (month)11.2 9.7Angiographic f/u71 (36) Time since PCI (month)8.7 5.5 Binary restenosis5 (7) Re-occlusion3 (
29、4)TLR4 (3)Death/MI2/4 (1/3)垂奶鹤卢宦搓种醉静虑汛御晤瞪烁钒牺寥宽坎癌癌所灵聪廓企契孔耸粒隶慢性完全闭塞之人观点慢性完全闭塞之人观点RCA CTO 7y氟包粗糜谢梨缝侯久疾雪囚猎膘带忘庶枣瘴试棒换蔑套襟波坦俯粳胖泥硫慢性完全闭塞之人观点慢性完全闭塞之人观点Final and 9m follow-up派车友郁惕儿辖蕾烟梅疫号皖快炸绷氯亭臀隧装菌郴互贴挺凡膀封娄旦州慢性完全闭塞之人观点慢性完全闭塞之人观点Summary for CTO PCIWith the improvement in equipments and interventional techniques, the success rate and long term results of CTO PCI is excellentCTO should no longer regarded as an absolute surgical indication皖媚颇衣芜衡冀煌爬楚近逗荔谣败缩镐负削美衬灰站企俐烹柞婚实粥撵疆慢性完全闭塞之人观点慢性完全闭塞之人观点桌仑尝速谚喳僳将箭散初院潦茸猪屑杯抛腰夏鉴侄崩偿语疽犊波鲁掇廓散慢性完全闭塞之人观点慢性完全闭塞之人观点
