慢性完全闭塞之个人观点

,按一下以編輯母片標題樣式,按一下以編輯母片文字樣式,第二層,第三層,第四層,第五層,*,*,按一下以編輯母片標題樣式,按一下以編輯母片文字樣式,第二層,第三層,第四層,第五層,*,*,按一下以編輯母片標題樣式,按一下以編輯母片文字樣式,第二層,第三層,第四層,第五層,*,*,按一下以編輯母片標題樣式,按一下以編輯母片文字樣式,第二層,第三層,第四層,第五層,*,*,按一下以編輯母片標題樣式,按一下以編輯母片文字樣式,第二層,第三層,第四層,第五層,*,*,按一下以編輯母片標題樣式,按一下以編輯母片文字樣式,第二層,第三層,第四層,第五層,*,*,按一下以編輯母片標題樣式,按一下以編輯母片文字樣式,第二層,第三層,第四層,第五層,*,按一下以編輯母片標題樣式,按一下以編輯母片文字樣式,第二層,第三層,第四層,第五層,*,Paul Hsien-Li Kao,MD,Assistant ProfessorNational 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,Success(N=286),Failure(N=83),P-value,All death,3(1.0%),3(3.6%),0.13,Cardiac death,1(0.3%),3(3.6%),0.03,Non-fatal QMI,1(0.3%,-,-,Non-fatal NQMI,1(0.3%),3(3.6%),0.03,Cardiac death/MI,3(1.0%),6(7.2%),0.005,CABG,7(2.4%),13(15.7%),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,N(%),Male,153(72),HTN,165(78),DM,79(37),HLP,110 (52),Smoker,104(49),CTO location LAD,102(42),LCX,53(22),RCA,81(33),LM,3(1),SVG,5(2),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,Reference diameter(mm),2.7 0.9,Occlusion length(mm),25.3 8.4,Final balloon-to-artery ratio,1.1 0.3,Residual stenosis(%),11 9,Guide wires used per lesion,2.4,Balloon used per lesion,1.9,Fluoroscopic time(min),42 38,Total procedure time(min),100 87,Contrast volume(ml),252 92,Procedure results,N,%,Wire crossing success,206/244,92,primary wire,27,11,parallel/seesaw wire,81,33,r