慢性完全闭塞病变既往经皮冠状动脉介入治疗失败后重新尝试的策略及技术的单中心分析

Strategies and techniques of reattempted percutaneous coronary intervention for chronic total occlusion prior failed procedures:Analysis of a single center retrospective

目的探讨对慢性完全闭塞(CTO)病变重新尝试经皮冠状动脉介入治疗(PCI)的策略和技术。方法连续入选2016年9月至2019年12月徐州市中心医院心内科住院行PCI的CTO病变患者258例,分为首次尝试组(206例)和重新尝试组(52例),分析与首次尝试组相比,重新尝试组的手术策略和技术以及临床结局的异同。结果重新尝试组靶病变解剖结构更为复杂,J-CTO评分高于首次尝试组[(3.2±1.1)分比(1.8±0.9)分,P<0.001]。重新尝试组器械成功率较首次尝试组偏低(76.9%比88.3%,P=0.034)。两组患者在手术策略方面比较:重新尝试组正向策略应用比例低于首次尝试组(71.2%比88.3%,P=0.002),而双向策略应用则高于首次尝试组(23.1%比7.8%,P=0.002),但在双向失败转正向策略应用上两组差异无统计学意义(5.8%比3.9%,P=0.467)。重新尝试组在平行导丝技术(43.2%比25.8%,P=0.033)、正向内膜下重回真腔技术(8.1%比0.5%,P=0.016)、血管内超声指导的正向技术(16.2%比3.8%,P=0.011)、反向控制性正向和逆向内膜下寻径技术(21.6%比2.2%,P<0.001)、抓捕技术(10.8%比1.6%,P=0.017)、Knuckle技术(8.1%比0.5%,P=0.016)的应用比例较多。两组患者冠状动脉穿孔以及住院期间主要不良心血管事件发生率比较,差异均无统计学意义(均P>0.05)。结论重新尝试的CTO-PCI,由于病变复杂,手术难度高,成功率较首次尝试组偏低。对于有经验的术者,通过分析首次尝试失败原因,可以更有针对性地制定手术策略和及时转换策略,并合理运用相关技术,仍可以取得较高的成功率。

Objective We aimed to investigate strategies and techniques for reattempted percutaneous coronary interventions(PCI)for chronic total occlusions(CTO)after prior failed attempt.Methods A total of 258 patients with CTO-PCI cases were consecutively collected in this study from September 2016 to December 2019 in department of cardiology,Xuzhou Central Hospital,including 206 patients of first-attempt CTO-PCI group and 52 patients of reattempted CTO-PCI group.Initial strategies and techniques and outcomes for reattempted CTO-PCI were evaluated and compared with first-attempt CTO-PCI.Results Re-attempted CTO-PCI lesions showed features of high anatomical complexity that required more complex and longer procedures for successful interventional revascularization.The mean J-CTO score of reattempt CTO-PCI was higher than that of first-attempt CTO-PCI[(3.2±1.1)points vs.(1.8±0.9)points,P<0.001].The instrument success rate of reattempt CTO-PCI was lower than that of first-attempt CTO-PCI(76.9%vs.88.3%,P=0.034).Antegrade approach alone in reattempt CTO-PCI was lower than that in first-attempt CTO-PCI(71.2%vs.88.3%,P=0.002),while the bidirectional approach was higher than that in first-attempt CTO-PCI(23.1%vs.7.8%,P=0.002),and there was no statistical difference in antegrade approach following a failed bidirectional approach between the two groups(reattempt:5.8%,first-attempt:3.9%,P=0.467).Parallel wire technique(PWT)(43.2%vs.25.8%,P=0.033),antegrade dissection reentry(ADR)(8.1%vs.0.5%,P=0.016),intravascular ultrasound guide crossing(16.2%vs.3.8%,P=0.011),reverse controlled antegrade and retrograde tracking(Reverse CART)(66.7%vs.25.0%,P=0.027),trapping technique(10.8%vs.1.6%,P=0.017),knuckle techniqae(8.1%vs.0.5%,P=0.016)were more applications in reattempt CTO-PCI.There was no significant difference between the two groups in the rates of coronary perforation and major cardiovascular events during hospitalization(all P>0.05).Conclusions The success rate of reattempt CTO-PCI is lower than that of firstattempt CTO-PCI.However,by analyzing the reasons for the failure of the first attempt,using more complex strategies and timely strategy transformation,the success rate of reattempt CTOPCI can be improved by highly skilled operators.