经皮冠状动脉介入治疗对慢性完全闭塞病变患者预后的影响
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摘要
目的评价经皮冠状动脉介入(percutaneous coronary intervention PCI)治疗开通慢性完全闭塞病变(CTO)对患者预后的影响。方法前瞻性连续性地选取2016年8月至2017年2月广东省心血管病研究所心内科二区病房共144例冠状动脉CTO住院患者为研究对象,记录患者临床基线特征及CTO开通策略、PCI治疗相关手术并发症和住院期间不良事件,根据手术是否成功分为成功组(n=125)和失败组(n=19)。术后3、6、12个月进行临床随访,随访主要终点事件为主要不良心血管事件(major adverse cardiovascularevent,MACE),包括全因死亡、非致死性心肌梗死(myocardial infarction,MI)或靶血管再次血运重建(targetvessel revascularization,TVR)。比较PCI治疗成功组与失败组患者预后的差别。结果 PCI治疗总成功率为86.8%(125/144)。随访时间为(11.49±2.01)个月,成功组患者总MACE发生率明显低于失败组,差异有统计学意义(5.6%vs. 26.3%,P=0.002);成功组累积无MACE生存率高于失败组(log rank P=0.025)。PCI治疗总的并发症发生率为6.3%(9/144)。与成功组相比,失败组的不良事件发生率较高(P=0.002)。此外,正向与逆向PCI治疗策略对患者累积无MACE生存率无影响(log rank P=0.954)。两种策略术中不良事件发生分别为5例(5.7%)和6例(15.8%),差异无统计学意义(P>0.05)。结论通过正向与逆向PCI治疗策略相结合的方法,开通CTO成功率高,术中并发症发生率较低。成功开通CTO能降低患者1年总MACE发生率,提高累积无MACE生存率。
Objectives To evaluate the clinical outcomes in patients with chronic coronary total occlusion(CTO)afterpercutaneous coronary intervention(PCI). Methods A total of 144 consecutive CTO patients who underwent PCIbetween August 2016 to February 2017 from Department of Cardiology,Guangdong Cardiovascular Institute were en-rolled in this study. The clinical data,coronary angiography characteristics,antegrade or retrograde interventionstrategies,complications of PCI and the procedural outcomes were recorded. These patients were divided into twogroups according to the procedural success(n=125)or failure(n=19). These patients were followed up at 3,6 and 12 months. Major adverse cardiovascular events(MACE),including all-cause mortality,nonfatal myocardial infarction(MI)and target vessel revascularization(TVR)were recorded and compared between the two groups. Results Overallsuccess rate of procedure was 86.8%(125/144). The mean duration of follow-up was(11.49±2.01)months. MACErate was significantly lower in patients with successful PCI of CTO compared to failed PCI of CTO(5.6% vs. 26.3%,log rank P=0.002). Patients with successful PCI of CTO experienced a higher no MACE survival rate(log rank P=0.025). Overall complication rate of procedure was 6.3%(9/144). Adverse procedural events rate was significantlyhigher in patients with failed PCI of CTO compared to successful PCI of CTO(P=0.002). The antegrade and ret-rograde interventions to recanalize CTO had no effect on MACE survival rate(log rank P=0.954). Conclusions CTOPCI is performed through a combination of antegrade and retrograde intervention strategies to achieve high successrate of revascularization and low complication rate. Successful PCI for CTO can reduce MACE rate and improve noMACE survival rate during first year after PCI.
Objectives To evaluate the clinical outcomes in patients with chronic coronary total occlusion(CTO)afterpercutaneous coronary intervention(PCI). Methods A total of 144 consecutive CTO patients who underwent PCIbetween August 2016 to February 2017 from Department of Cardiology,Guangdong Cardiovascular Institute were en-rolled in this study. The clinical data,coronary angiography characteristics,antegrade or retrograde interventionstrategies,complications of PCI and the procedural outcomes were recorded. These patients were divided into twogroups according to the procedural success(n=125)or failure(n=19). These patients were followed up at 3,6 and 12 months. Major adverse cardiovascular events(MACE),including all-cause mortality,nonfatal myocardial infarction(MI)and target vessel revascularization(TVR)were recorded and compared between the two groups. Results Overallsuccess rate of procedure was 86.8%(125/144). The mean duration of follow-up was(11.49±2.01)months. MACErate was significantly lower in patients with successful PCI of CTO compared to failed PCI of CTO(5.6% vs. 26.3%,log rank P=0.002). Patients with successful PCI of CTO experienced a higher no MACE survival rate(log rank P=0.025). Overall complication rate of procedure was 6.3%(9/144). Adverse procedural events rate was significantlyhigher in patients with failed PCI of CTO compared to successful PCI of CTO(P=0.002). The antegrade and ret-rograde interventions to recanalize CTO had no effect on MACE survival rate(log rank P=0.954). Conclusions CTOPCI is performed through a combination of antegrade and retrograde intervention strategies to achieve high successrate of revascularization and low complication rate. Successful PCI for CTO can reduce MACE rate and improve noMACE survival rate during first year after PCI.
引文
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[9]罗初凡,杜志民,胡承恒,等.慢性完全闭塞冠状动脉介入治疗对远期预后的影响[J].中华心血管病杂志,2005,33(z1):38-41.
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[11]赵季平,宋现涛.药物洗脱支架对开通冠状动脉慢性完全闭塞病变患者预后的影响[J].心肺血管病杂志,2016(4):269-274.
[12]PRASAD A,RIHAL C S,LENNON R J,et al.Trends in outcomes after percutaneous coronary intervention for chronic total occlusions:a 25-year experience from the Mayo Clinic[J].JAm Coll Cardiol,2007,49(15):1611-1618.
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[14]LEE P H,LEE S W,PARK H S,et al.Successful recanalization of native coronary chronic total occlusion is not associated with improved long-term survival[J].JACC Cardiovasc Interv,2016,9(6):530-538.
[15]WERNER G S.A Randomized multicentre trial to evaluate the utilization of revascularization or optimal medical therapy for the treatment of chronic total coronary occlusions(EuroCTO)(ClinicalTrials.gov Identifier:NCT01760083)[R].Paris:EuroPCRCongress,2017.
[16]PARK S J.Optimal medical therapy with or without stenting for coronary chronic total occlusion:DECISION-CTO.(ClinicalTrials.gov Identifier:NCT01078051)[R].Washington,DC:American College Cardiology Congress,2017.
[17]DI MARIO C,WERNER G S,SIANOS G,et al.European perspective in the recanalisation of chronic total occlusions(CTO):consensus document from the EuroCTO Club[J].EuroIntervention,2007,3(1):30-43.
[18]MORINO Y,ABE M,MORIMOTO T,et al.Predicting successful guidewire crossing through chronic total occlusion of native coronary lesions within 30 minutes:the J-CTO(Multicenter CTO Registry in Japan)score as a difficulty grading and time assessment tool[J].JACC Cardiovasc Interv,2011,4(2):213-221.
[19]CHAI W L,AGYEKUM F,ZHANG B,et al.Clinical prediction score for successful retrograde procedure in chronic total occlusion percutaneous coronary intervention[J].Cardiology,2016,134(3):331-339.
[20]WERNER G S,FERRARI M,HEINKE S,et al.Angiographic assessment of collateral connections in comparison with invasively determined collateral function in chronic coronary occlusions[J].Circulation,2003,107(15):1972-1977.
[21]THYGESEN K,ALPERT J S,WHITE H D.Universal definition of myocardial infarction[J].J Am Coll Cardiol,2007,50(22):2173-2195.
[22]JOYAL D,AFILALO J,RINFRET S.Effectiveness of recanalization of chronic total occlusions:a systematic review and meta-analysis[J].Am Heart J,2010,160(1):179-187.
[23]SURMELY J F,TSUCHIKANE E,KATOH O,et al.New concept for CTO recanalization using controlled antegrade and retrograde subintimal tracking:the CART technique[J].J Invasive Cardiol,2006,18(7):334-338.
[24]TSUCHIKANE E,YAMANE M,MUTOH M,et al.Japanese multicenter registry evaluating the retrograde approach for chronic coronary total occlusion[J].Catheter Cardiovasc Interv,2013,82(5):E654-E661.
[25]KARMPALIOTIS D,MICHAEL T T,BRILAKIS E S,et al.Retrograde coronary chronic total occlusion revascularization:procedural and in-hospital outcomes from a multicenter registry in the United States[J].JACC Cardiovasc Interv,2012,5(12):1273-1279.
[26]GALASSI A R,SIANOS G,WERNER G S,et al.Retrograde recanalization of chronic total occlusions in Europe:procedural,in-hospital,and long-term outcomes from the multicenter ERCTO registry[J].J Am Coll Cardiol,2015,65(22):2388-2400.
[27]张斌,廖洪涛,靳立军,等.反向CART技术治疗冠状动脉慢性完全闭塞病变[J].中国介入心脏病学杂志,2010,18(1):47-49.
[28]张斌,廖洪涛,靳立军,等.经心外膜下侧支循环逆向介入治疗冠状动脉慢性完全闭塞病变[J].中华心血管病杂志,2010,38(9):794-797.
[29]张斌,王锋,廖洪涛,等.经单桡动脉途径行慢性完全闭塞病变介入治疗同时行对侧造影的可行性[J].中华心血管病杂志,2013,41(2):108-110.
[30]张传寿,廖洪涛,张斌,等.冠状动脉内旋磨术在慢性完全闭塞病变介入治疗中的应用[J].中国介入心脏病学杂志,2014,22(2):111-113.
[31]张斌,廖洪涛,马墩亮.逆向经皮冠状动脉介入治疗左前降支的慢性完全闭塞病变[J].中国介入心脏病学杂志,2014(6):401-402.
[32]柴玮璐,廖洪涛,张斌,等.穿微导管技术在逆向经皮冠状动脉介入治疗中的应用[J].中国介入心脏病学杂志,2015(9):500-503.
[33]HUANG Z,ZHANG B,CHAI W,et al.Usefulness and safety of a novel modification of the retrograde approach for the long tortuous chronic total occlusion of coronary arteries[J].Int Heart J,2017,58(3):351-356.
[34]林敬业,钟志安,张斌,等.Knuckle技术辅助反向控制性正向和逆向内膜下寻径技术治疗钙化迂曲的冠状动脉慢性完全闭塞病变[J].中国介入心脏病学杂志,2018(6):316-319.
[35]黄泽涵,张斌,廖洪涛,等.Guidezilla~(TM)延长导管在冠状动脉慢性完全闭塞病变反向控制性前向与逆向内膜下寻径技术中的应用[J].中国介入心脏病学杂志,2018(4):219-224.
[36]GAO L,WANG Y,LIU Y,et al.Long-term clinical outcomes of successful revascularization with drug-eluting stents for chronic total occlusions:A systematic review and meta-analysis[J].Catheter Cardiovasc Interv,2017,89(S1):574-581.
[37]NOMBELA-FRANCO L,MITROI C D,FERNANDEZ-LOZA-NO I,et al.Ventricular arrhythmias among implantable cardioverter-defibrillator recipients for primary prevention:impact of chronic total coronary occlusion(VACTO Primary Study)[J].Circ Arrhythm Electrophysiol,2012,5(1):147-154.
[38]GALASSI A R,BOUKHRIS M,TOMA A,et al.Percutaneous coronary intervention of chronic total occlusions in patients with low left ventricular ejection fraction[J].JACC Cardiovasc Interv,2017,10(21):2158-2170.
[2]CHRISTOFFERSON R D,LEHMANN K G,MARTIN G V,et al.Effect of chronic total coronary occlusion on treatment strategy[J].Am J Cardiol,2005,95(9):1088-1091.
[3]JOYAL D,AFILALO J,RINFRET S.Effectiveness of recanalization of chronic total occlusions:a systematic review and meta-analysis[J].Am Heart J,2010,160(1):179-187.
[4]MEHRAN R,CLAESSEN B E,GODINO C,et al.Long-term outcome of percutaneous coronary intervention for chronic total occlusions[J].JACC Cardiovasc Interv,2011,4(9):952-961.
[5]LADWINIEC A,ALLGAR V,THACKRAY S,et al.Medical therapy,percutaneous coronary intervention and prognosis in patients with chronic total occlusions[J].Heart,2015,101(23):1907-1914.
[6]GALASSI A R,SIANOS G,WERNER G S,et al.Retrograde recanalization of chronic total occlusions in Europe:procedural,in-hospital,and long-term outcomes from the multicenter ERC-TO registry[J].J Am Coll Cardiol,2015,65(22):2388-2400.
[7]TOMA A,GICK M,MINNERS J,et al.Survival after percutaneous coronary intervention for chronic total occlusion[J].Clin Res Cardiol,2016,105(11):921-929.
[8]SAPONTIS J,SALISBURY A C,YEH R W,et al.Early procedural and health status outcomes after chronic total occlusion angioplasty:a report from the OPEN-CTO registry(Outcomes,Patient Health Status,and Efficiency in Chronic Total Occlusion Hybrid Procedures)[J].JACC Cardiovasc Interv,2017,10(15):1523-1534.
[9]罗初凡,杜志民,胡承恒,等.慢性完全闭塞冠状动脉介入治疗对远期预后的影响[J].中华心血管病杂志,2005,33(z1):38-41.
[10]伊宪华,韩雅玲,李毅,等.介入治疗开通慢性完全闭塞病变的长期临床疗效[J].中华心血管病杂志,2009,37(9):773-776.
[11]赵季平,宋现涛.药物洗脱支架对开通冠状动脉慢性完全闭塞病变患者预后的影响[J].心肺血管病杂志,2016(4):269-274.
[12]PRASAD A,RIHAL C S,LENNON R J,et al.Trends in outcomes after percutaneous coronary intervention for chronic total occlusions:a 25-year experience from the Mayo Clinic[J].JAm Coll Cardiol,2007,49(15):1611-1618.
[13]KIM B S,YANG J H,JANG W J,et al.Clinical outcomes of multiple chronic total occlusions in coronary arteries according to three therapeutic strategies:Bypass surgery,percutaneous intervention and medication[J].Int J Cardiol,2015,197:2-7.
[14]LEE P H,LEE S W,PARK H S,et al.Successful recanalization of native coronary chronic total occlusion is not associated with improved long-term survival[J].JACC Cardiovasc Interv,2016,9(6):530-538.
[15]WERNER G S.A Randomized multicentre trial to evaluate the utilization of revascularization or optimal medical therapy for the treatment of chronic total coronary occlusions(EuroCTO)(ClinicalTrials.gov Identifier:NCT01760083)[R].Paris:EuroPCRCongress,2017.
[16]PARK S J.Optimal medical therapy with or without stenting for coronary chronic total occlusion:DECISION-CTO.(ClinicalTrials.gov Identifier:NCT01078051)[R].Washington,DC:American College Cardiology Congress,2017.
[17]DI MARIO C,WERNER G S,SIANOS G,et al.European perspective in the recanalisation of chronic total occlusions(CTO):consensus document from the EuroCTO Club[J].EuroIntervention,2007,3(1):30-43.
[18]MORINO Y,ABE M,MORIMOTO T,et al.Predicting successful guidewire crossing through chronic total occlusion of native coronary lesions within 30 minutes:the J-CTO(Multicenter CTO Registry in Japan)score as a difficulty grading and time assessment tool[J].JACC Cardiovasc Interv,2011,4(2):213-221.
[19]CHAI W L,AGYEKUM F,ZHANG B,et al.Clinical prediction score for successful retrograde procedure in chronic total occlusion percutaneous coronary intervention[J].Cardiology,2016,134(3):331-339.
[20]WERNER G S,FERRARI M,HEINKE S,et al.Angiographic assessment of collateral connections in comparison with invasively determined collateral function in chronic coronary occlusions[J].Circulation,2003,107(15):1972-1977.
[21]THYGESEN K,ALPERT J S,WHITE H D.Universal definition of myocardial infarction[J].J Am Coll Cardiol,2007,50(22):2173-2195.
[22]JOYAL D,AFILALO J,RINFRET S.Effectiveness of recanalization of chronic total occlusions:a systematic review and meta-analysis[J].Am Heart J,2010,160(1):179-187.
[23]SURMELY J F,TSUCHIKANE E,KATOH O,et al.New concept for CTO recanalization using controlled antegrade and retrograde subintimal tracking:the CART technique[J].J Invasive Cardiol,2006,18(7):334-338.
[24]TSUCHIKANE E,YAMANE M,MUTOH M,et al.Japanese multicenter registry evaluating the retrograde approach for chronic coronary total occlusion[J].Catheter Cardiovasc Interv,2013,82(5):E654-E661.
[25]KARMPALIOTIS D,MICHAEL T T,BRILAKIS E S,et al.Retrograde coronary chronic total occlusion revascularization:procedural and in-hospital outcomes from a multicenter registry in the United States[J].JACC Cardiovasc Interv,2012,5(12):1273-1279.
[26]GALASSI A R,SIANOS G,WERNER G S,et al.Retrograde recanalization of chronic total occlusions in Europe:procedural,in-hospital,and long-term outcomes from the multicenter ERCTO registry[J].J Am Coll Cardiol,2015,65(22):2388-2400.
[27]张斌,廖洪涛,靳立军,等.反向CART技术治疗冠状动脉慢性完全闭塞病变[J].中国介入心脏病学杂志,2010,18(1):47-49.
[28]张斌,廖洪涛,靳立军,等.经心外膜下侧支循环逆向介入治疗冠状动脉慢性完全闭塞病变[J].中华心血管病杂志,2010,38(9):794-797.
[29]张斌,王锋,廖洪涛,等.经单桡动脉途径行慢性完全闭塞病变介入治疗同时行对侧造影的可行性[J].中华心血管病杂志,2013,41(2):108-110.
[30]张传寿,廖洪涛,张斌,等.冠状动脉内旋磨术在慢性完全闭塞病变介入治疗中的应用[J].中国介入心脏病学杂志,2014,22(2):111-113.
[31]张斌,廖洪涛,马墩亮.逆向经皮冠状动脉介入治疗左前降支的慢性完全闭塞病变[J].中国介入心脏病学杂志,2014(6):401-402.
[32]柴玮璐,廖洪涛,张斌,等.穿微导管技术在逆向经皮冠状动脉介入治疗中的应用[J].中国介入心脏病学杂志,2015(9):500-503.
[33]HUANG Z,ZHANG B,CHAI W,et al.Usefulness and safety of a novel modification of the retrograde approach for the long tortuous chronic total occlusion of coronary arteries[J].Int Heart J,2017,58(3):351-356.
[34]林敬业,钟志安,张斌,等.Knuckle技术辅助反向控制性正向和逆向内膜下寻径技术治疗钙化迂曲的冠状动脉慢性完全闭塞病变[J].中国介入心脏病学杂志,2018(6):316-319.
[35]黄泽涵,张斌,廖洪涛,等.Guidezilla~(TM)延长导管在冠状动脉慢性完全闭塞病变反向控制性前向与逆向内膜下寻径技术中的应用[J].中国介入心脏病学杂志,2018(4):219-224.
[36]GAO L,WANG Y,LIU Y,et al.Long-term clinical outcomes of successful revascularization with drug-eluting stents for chronic total occlusions:A systematic review and meta-analysis[J].Catheter Cardiovasc Interv,2017,89(S1):574-581.
[37]NOMBELA-FRANCO L,MITROI C D,FERNANDEZ-LOZA-NO I,et al.Ventricular arrhythmias among implantable cardioverter-defibrillator recipients for primary prevention:impact of chronic total coronary occlusion(VACTO Primary Study)[J].Circ Arrhythm Electrophysiol,2012,5(1):147-154.
[38]GALASSI A R,BOUKHRIS M,TOMA A,et al.Percutaneous coronary intervention of chronic total occlusions in patients with low left ventricular ejection fraction[J].JACC Cardiovasc Interv,2017,10(21):2158-2170.
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