逆向技术用于冠状动脉慢性完全闭塞病变治疗的回顾性分析

Retrospective analysis of retrograde technique in the treatment of chronic total occlusion

目的回顾性分析慢性完全闭塞(CTO)病变行逆向经皮冠状动脉介入治疗(PCI患者资料,探讨逆向技术常见失败原因。方法自2016年12月至2018年12月宁夏医科大学总医院心脑血管病医院使用逆向技术的CTO-PCI患者共47例,其中包括逆向失败组15例,逆向成功组32例。分析其J-CTO评分、成功率和失败率及其原因。结果失败组平均J-CTO评分较高为(2.73±0.6)分,成功组(2.34±0.6)分,差异有统计学意义(P=0.043),且失败组中J-CTO评分≥3分比例显著高于成功组(80.0%比34.4%,P=0.040),但J-CTO评分2分显著低于成功组(13.3%比59.4%,P=0.030)。右冠状动脉为主要靶血管(36/47,76.6%),逆向侧支中高达91.4%(43/47)的患者选用室间隔支。失败组中CC分级0级显著高于成功组(46.7%比9.4%,P=0.040),差异有统计学意义。失败组中33.3%患者直接使用逆向技术,66.7%患者因前向技术失败转为逆向技术。而成功组中直接逆向为12.5%,前向失败转逆向占87.5%。失败组中反向控制性前向与逆向内膜下寻径(rCART)技术的使用率显著低于成功组(20.0%比65.6%,P=0.005),延长导管使用比例显著低于成功组(6.7%比53.1%,P=0.002),差异均有统计学意义。15例失败患者中逆向导丝不能通过侧支4例(26.7%);逆向导丝未能通过CTO病变5例(33.3%),其中包括2例直接r CART失败,1例血管内超声(IVUS)引导下r CART失败,1例IVUS引导下未能找到CTO开口失败,1例因闭塞段严重钙化导丝未能通过;3例(20.0%)因微导管不能通过CTO病变失败;2例因并发症终止手术,其中包括1例(6.7%)因术中逆向Knuckle导丝后出现心脏压塞终止手术,另1例因间隔支破裂,使用凝胶海绵封堵后失去逆向通路;1例患者因腰椎疾病不能坚持手术。结论逆向CTO-PCI失败主要原因为逆向导丝未能通过CTO病变,逆向导丝不能通过侧支,rCART失败,微导管不能通过CTO病变,手术并发症终止等。

Objective In this paper,we analyzed the retrograde chronic total occlusion percutaneous coronary intervention(CTO-PCI) cases retrospectively to explore the common failure reasons. Methods A total of 47 patients with retrograde CTO-PCI cases were collected in this study from December 2016 to December 2018 in the Cardio-cerebro-vascular hospital of NingXia Medical University,including 15 patients in failed group and 32 patients in success group. Results The average J-CTO score in all the cases was(2.54±0.6),the utilization rate of intravascular ultrasound(IVUS)was 17%,the mean contrast volume was 236 ml, and the overall success rate of retrograde CTO-PCI was 68.1%(32/47). The reverse controlled antegrade and retrograde subintimal tracking(CART) techniques were used in 21 cases(65.6%) of the success group, and 17 cases(53.1%) has used Guidezilla guide extension catheter. The main failure reasons in the failed group were as follow:4 cases(26.7%)were stopped due to inability to cross the collateral channel by retrograde guidewires;5 cases(33.3%)failed because the retrograde guidewires were unable to go through the CTO lesions, including 3 cases failed with reverse CART failure. Another 3 cases(20.0%)failed because the retrograde microcatheter could not cross the CTO lesion. 2 cases(13.3%)were terminated due to complications. Conclusions The main failure reasons of the retrograde technique in CTO was unable to cross the collateral or CTO lesions by guidewires and microcatheters,failed to do reverse CART,few of the procedures were terminated due to complications.