RSS-Feed abonnieren
DOI: 10.1055/a-0527-9651
Komplexe Koronarinterventionen
Publikationsverlauf
Publikationsdatum:
11. Dezember 2018 (online)
![](https://www.thieme-connect.de/media/kardiologie-u2d/201804/lookinside/thumbnails/10-1055-a-0527-9651_kd5279651_neumann-1.jpg)
Die koronare Herzerkrankung (KHK) gehört weltweit zu den führenden Todesursachen. Medikamentöse Therapie, die perkutane koronare Intervention (PCI) und Bypassoperation sind die therapeutischen Möglichkeiten der KHK. Bei der PCI gehören Bifurkationsstenosen, kalzifizierte Läsionen und chronische Koronarverschlüsse zu den besonderen Herausforderungen.
-
Die primäre Behandlungsstrategie koronarer Bifurkationsstenosen basiert auf der Stentimplantation im Hauptast mit nur bedarfsweiser Stentimplantation im Seitenast („provisional“ T-Stenting).
-
Zwei-Stent-Techniken wie TAP-, Culotte- und DK-Crush-Stenting sind in ca. 20% der Fälle erforderlich, um ein optimales angiografisches Ergebnis zu erzielen.
-
Die aktuelle Datenlage unterstützt den Einsatz der DK-Crush-Technik bei der PCI der linken Hauptstammstenose.
-
Eine optimale Plaquemodifikation ist bei einer PCI stark verkalkter Koronargefäße der wesentliche Schlüssel zum Erfolg.
-
Dabei können Verfahren wie die Rotablation und die Ultrahochdruckangioplastie zu einer verbesserten Stentapposition und Stentexpansion verhelfen.
-
CTOs finden sich bei ca. 20% aller angiografierten Patienten. Nicht selten liegt eine reine Belastungsdyspnoe als führendes Symptom vor.
-
Die Indikation zur Rekanalisierung einer CTO wird symptomorientiert oder nach Ischämie- und Vitalitätsnachweis gestellt. Patienten mit Mehrgefäßerkrankung sollten, wenn immer möglich, komplett unter Miteinbeziehung der CTO revaskularisiert werden.
-
Literatur
- 1 Lassen JF, Burzotta F, Banning AP. et al. Percutaneous coronary intervention for the left main stem and other bifurcation lesions: 12th consensus document from the European Bifurcation Club. EuroIntervention 2018; 13: 1540-1553 doi:10.4244/EIJ-D-17-00622
- 2 Steigen TK, Maeng M, Wiseth R. et al. Randomized study on simple versus complex stenting of coronary artery bifurcation lesions: the Nordic bifurcation study. Circulation 2006; 114: 1955-1961 doi:10.1161/CIRCULATIONAHA.106.664920
- 3 Ferenc M, Gick M, Kienzle RP. et al. Randomized trial on routine vs. provisional T-stenting in the treatment of de novo coronary bifurcation lesions. Eur Heart J 2008; 29: 2859-2867 doi:10.1093/eurheartj/ehn455
- 4 Erglis A, Kumsars I, Niemela M. et al. Randomized comparison of coronary bifurcation stenting with the crush versus the culotte technique using sirolimus eluting stents: the Nordic stent technique study. Circ Cardiovasc Interv 2009; 2: 27-34 doi:10.1161/CIRCINTERVENTIONS.108.804658
- 5 Chen SL, Zhang JJ, Ye F. et al. Study comparing the double kissing (DK) crush with classical crush for the treatment of coronary bifurcation lesions: the DKCRUSH-1 Bifurcation Study with drug-eluting stents. Eur J Clin Invest 2008; 38: 361-371 doi:10.1111/j.1365-2362.2008.01949.x
- 6 Chen SL, Santoso T, Zhang JJ. et al. A randomized clinical study comparing double kissing crush with provisional stenting for treatment of coronary bifurcation lesions: results from the DKCRUSH-II (Double Kissing Crush versus Provisional Stenting Technique for Treatment of Coronary Bifurcation Lesions) trial. J Am Coll Cardiol 2011; 57: 914-920 doi:10.1016/j.jacc.2010.10.023
- 7 Gudmundsdottir I, Adamson P, Gray C. et al. Optical coherence tomography versus intravascular ultrasound to evaluate stent implantation in patients with calcific coronary artery disease. Open Heart 2015; 2: e000225 doi:10.1136/openhrt-2014-000225
- 8 Chen SL, Zhang JJ, Han Y. et al. Double Kissing Crush Versus Provisional Stenting for Left Main Distal Bifurcation Lesions: DKCRUSH-V Randomized Trial. J Am Coll Cardiol 2017; 70: 2605-2617 doi:10.1016/j.jacc.2017.09.1066
- 9 Ferenc M, Banholzer N, Hochholzer W. et al. Long-term results after PCI of unprotected distal left main coronary artery stenosis: the Bifurcations Bad Krozingen (BBK)-Left Main Registry. Clin Res Cardiol 2018; DOI: 10.1007/s00392-018-1337-9.
- 10 Kim SW, Mintz GS, Lee WS. et al. DICOM-based intravascular ultrasound signal intensity analysis: an Echoplaque Medical Imaging Bench study. Coron Artery Dis 2014; 25: 236-241 doi:10.1097/MCA.0000000000000077
- 11 Jones DA, Rathod KS, Koganti S. et al. Angiography Alone Versus Angiography Plus Optical Coherence Tomography to Guide Percutaneous Coronary Intervention: Outcomes From the Pan-London PCI Cohort. JACC Cardiovasc Interv 2018; 11: 1313-1321 doi:10.1016/j.jcin.2018.01.274
- 12 Ali ZA, Maehara A, Genereux P. et al. Optical coherence tomography compared with intravascular ultrasound and with angiography to guide coronary stent implantation (ILUMIEN III: OPTIMIZE PCI): a randomised controlled trial. Lancet 2016; 388: 2618-2628 doi:10.1016/S0140-6736(16)31922-5
- 13 Abdel-Wahab M, Richardt G, Joachim Buttner H. et al. High-speed rotational atherectomy before paclitaxel-eluting stent implantation in complex calcified coronary lesions: the randomized ROTAXUS (Rotational Atherectomy Prior to Taxus Stent Treatment for Complex Native Coronary Artery Disease) trial. JACC Cardiovasc Interv 2013; 6: 10-19 doi:10.1016/j.jcin.2012.07.017
- 14 Bangalore S, Vlachos HA, Selzer F. et al. Percutaneous coronary intervention of moderate to severe calcified coronary lesions: insights from the National Heart, Lung, and Blood Institute Dynamic Registry. Catheter Cardiovasc Interv 2011; 77: 22-28 doi:10.1002/ccd.22613
- 15 Vaquerizo B, Serra A, Miranda F. et al. Aggressive plaque modification with rotational atherectomy and/or cutting balloon before drug-eluting stent implantation for the treatment of calcified coronary lesions. J Interv Cardiol 2010; 23: 240-248 doi:10.1111/j.1540-8183.2010.00547.x
- 16 Fefer P, Knudtson ML, Cheema AN. et al. Current perspectives on coronary chronic total occlusions: the Canadian Multicenter Chronic Total Occlusions Registry. J Am Coll Cardiol 2012; 59: 991-997 doi:10.1016/j.jacc.2011.12.007
- 17 Mashayekhi K, Neuser H, Kraus A. et al. Successful Percutaneous Coronary Intervention Improves Cardiopulmonary Exercise Capacity in Patients With Chronic Total Occlusions. J Am Coll Cardiol 2017; 69: 1095-1096 doi:10.1016/j.jacc.2016.12.017
- 18 Garcia S, Sandoval Y, Roukoz H. et al. Outcomes after complete versus incomplete revascularization of patients with multivessel coronary artery disease: a meta-analysis of 89,883 patients enrolled in randomized clinical trials and observational studies. J Am Coll Cardiol 2013; 62: 1421-1431 doi:10.1016/j.jacc.2013.05.033
- 19 Head SJ, Mack MJ, Holmes jr. DR. et al. Incidence, predictors and outcomes of incomplete revascularization after percutaneous coronary intervention and coronary artery bypass grafting: a subgroup analysis of 3-year SYNTAX data. Eur J Cardiothorac Surg 2012; 41: 535-541 doi:10.1093/ejcts/ezr105
- 20 Hannan EL, Racz M, Holmes DR. et al. Impact of completeness of percutaneous coronary intervention revascularization on long-term outcomes in the stent era. Circulation 2006; 113: 2406-2412 doi:10.1161/CIRCULATIONAHA.106.612267
- 21 George S, Cockburn J, Clayton TC. et al. Long-term follow-up of elective chronic total coronary occlusion angioplasty: analysis from the U.K. Central Cardiac Audit Database. J Am Coll Cardiol 2014; 64: 235-243 doi:10.1016/j.jacc.2014.04.040
- 22 Tajti P, Karmpaliotis D, Alaswad K. et al. The Hybrid Approach to Chronic Total Occlusion Percutaneous Coronary Intervention: Update From the PROGRESS CTO Registry. JACC Cardiovasc Interv 2018; 11: 1325-1335 doi:10.1016/j.jcin.2018.02.036
- 23 Sapontis J, Salisbury AC, Yeh RW. 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). JACC Cardiovasc Interv 2017; 10: 1523-1534 doi:10.1016/j.jcin.2017.05.065
- 24 Maeremans J, Walsh S, Knaapen P. et al. The Hybrid Algorithm for Treating Chronic Total Occlusions in Europe: The RECHARGE Registry. J Am Coll Cardiol 2016; 68: 1958-1970 doi:10.1016/j.jacc.2016.08.034
- 25 Morino Y, Kimura T, Hayashi Y. et al. In-hospital outcomes of contemporary percutaneous coronary intervention in patients with chronic total occlusion insights from the J-CTO Registry (Multicenter CTO Registry in Japan). JACC Cardiovasc Interv 2010; 3: 143-151 doi:10.1016/j.jcin.2009.10.029
- 26 Konstantinidis NV, Werner GS, Deftereos S. Temporal trends in chronic total occlusion interventions in europe. Circ Cardiovasc Interv 2018; 11: e006229 doi:10.1161/CIRCINTERVENTIONS.117.006229
- 27 Azzalini L, Agostoni P, Benincasa S. et al. Retrograde Chronic Total Occlusion Percutaneous Coronary Intervention Through Ipsilateral Collateral Channels: A Multicenter Registry. JACC Cardiovasc Interv 2017; 10: 1489-1497 doi:10.1016/j.jcin.2017.06.002
- 28 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. JACC Cardiovasc Interv 2011; 4: 213-221 doi:10.1016/j.jcin.2010.09.024