逆向导丝技术治疗冠状动脉慢性完全闭塞病变255例临床分析

Retrograde wire technique for the treatment of chronic coronary artery occlusion: an analysis of 255 cases

目的探讨逆向导丝技术治疗冠状动脉慢性完全闭塞（CTO）病变的技术及疗效。方法收集沈阳军区总医院2004年8月至2015年5月收治的CTO病变患者。患者因正向导丝通过闭塞血管失败或冠状动脉造影（SCA）后估测正向导丝通过闭塞血管困难,并且侧支循环交通血管良好的冠状动脉CTO患者采取逆向导丝技术行冠脉内支架植入术,并进行术后随访。总结分析全部患者临床资料。结果共纳入255例患者,共开通CTO病变血管255支,平均闭塞时间为（4.35±3.98）年。其中左前降支（LAD）闭塞病变117例,右冠状动脉（RCA）闭塞病变132例,闭塞病变均有2~3级逆向侧支血管供血。术中平均应用造影剂（320.0±65.6）m L/例,药物洗脱支架平均（57.67±19.86）mm/例。一次手术成功率220例,再次手术成功20例,失败15例。88.9%患者采用右桡及右股动脉路入,11.1%应用双股动脉路入并使用8 F（1 F=0.33 mm）指引导管。术后患者均规律服用抗血小板及他汀类药物,并进行了电话和临床随访6~12个月,其中91.4%LAD CTO病变开通后患者心功能较前改善;86.1%RCA CTO开通后患者自觉症状改善。15例手术失败患者有1例接受冠状动脉旁路移植术（CABG）,1例手术成功患者术后6个月出现心绞痛症状,行SCA检查示RCA支架100%闭塞,并成功接受二次逆向导丝,手术成功;患者术后无心血管主要临床事件发生。结论多数正向导丝技术无法完成的冠脉病变,逆向导丝技术可明显提高手术成功率,发现及选择那些具有良好侧支循环及逆向通道的冠状动脉CTO病变进行逆向导丝介入治疗是安全、可行的,并可收到良好的疗效。

Objective To investigate the feasibility and safety of retrograde wire technique for the treatment of patients with chronic coronary artery occlusion. Methods A total of 255 patients with chronic coronary artery occlusion（chronic total occlusion, CTO）, who received percutaneous coronary artery intervention（PCI） by retrograde wire technique following failure of routine transcutaneous antegrade wire technique or due to estimated difficulty in the antegrade operation in General Hospital of Shenyang Military Command, were followed up from August 2004 to May 2015 by angiography or on telephone. The clinical data of all those patients were summarized. Results Of the 255 patients, a total of 240 CTO vessels were opened, and the average occlusion time was 3.3 years. There were 117 cases of left anterior descending（LAD） CTO and 132 cases of right coronary artery（RCA） CTO, with grade 2-3 retrograde collateral blood supply at all occlusion lesions. Among the 240 patients, the averages of drug-eluting stents, guide wires and microcatheters used were 3.6, 5.4 and 1.7 per patient, and the intravascular contrast media used was 320 m L per patient. The first operations succeeded in 220 cases, re-operations in 20 cases, but operations failed in 10 cases. Guided catheter placement by right radial and right femoral approach was in 88.9% patients, and bilateral femoral placement was performed in 11.1% patients with 8 F（1 F=0.33 mm） guided catheters. The improvement rate of heart function and angina pectoris was 91.4% in LAD CTO cases and 86.1% in RCA CTO cases. Operative failures occurred in 15 patients of 255 cases with 1 case received coronary artery bypass grafting. Only 1 patient received a second-time PCI due to coronary stent occlusion 8 months later and succeeded. No major events such as death and myocardial infarction occurred. Conclusion Retrograde intervention is feasible and safe for patients with CTO. Careful evaluation on CTO lesion is a key to obtain a relatively high success rate of PCI. Retrograde wire technique significantly increases the success rate of procedures in patients who failed in treatment of antegrade wire technique.