RSS-Feed abonnieren
DOI: 10.1055/s-0032-1325077
Die chronische Koronarokklusion
Chronic Coronary OcclusionPublikationsverlauf
Publikationsdatum:
06. August 2013 (online)
![](https://www.thieme-connect.de/media/aktkardio/201304/lookinside/thumbnails/10.1055-s-0032-1325077-1.jpg)
Zusammenfassung
Die Wiedereröffnung chronischer Koronarokklusionen unterscheidet sich maßgeblich von der Koronarangioplastie stenosierter Gefäße und gilt als die größte interventionelle Herausforderung. Das Verfahren hat sich in den letzten 10 Jahren sehr entwickelt und verfeinert und in den Händen Geübter zu einer Steigerung der Erfolgsrate von etwa 60 % auf über 90 % geführt. Durch Einsatz medikamentenbeschichteter Stents wird heute eine Offenrate von ebenfalls über 90 % erzielt Diese Ergebnisse sind denen der Bypassoperation ebenbürtig oder gar überlegen. In der vorliegenden Arbeit werden einige für die CTO-PCI speziell entwickelte Techniken beschrieben und es wird unterstrichen, dass eine gezielte Anleitung und kontinuierliches Training notwendig ist, um die in den Leitlinien der ESC/EACTS geforderte Erfolgsrate von mindestens 80 % zu erreichen und sicherzustellen, dass Patienten, die eine Revaskularisation benötigen, diese nicht vorenthalten wird.
Abstract
Percutaneous coronary intervention for chronic total occlusions markedly differs from PCI of stenotic lesions and is considered the most difficult and time consuming intervention. The procedure is evolving rapidly, well documented by a success rate that increased in the hands of specifically trained operators from about 60 % to over 90 % in the past 10 years, the long-term patency with drug eluting stents exceeding 90 %. These results are comparable or even superior to surgical revascularisation. Several sophisticated techniques unique to CTO interventions are described and the need for specific training is emphasised so that the success rate of at least 80 % as claimed by the ESC guidelines on myocardial revascularisation can be met and patients with CTO who deserve revascularisation are no longer denied appropriate treatment.
-
Literatur
- 1 Di Mario C et al. European perspective in the recanalisation of Chronic Total Occlusions (CTO): consensus document from the EuroCTO Club. EuroIntervention 2007; 3: 30-43
- 2 Joyal D, Afilalo J, Rinfret S. Effectiveness of recanalization of chronic total occlusions: a systematic review and meta-analysis. Am Heart J 2010; 160: 179-187
- 3 Fefer P et al. Current perspectives on coronary chronic total occlusions: the Canadian Multicenter Chronic Total Occlusions Registry. J Am Coll Cardiol 2012; 59: 991-997
- 4 Wijns W, Kolh P, Danchin N et al. Guidelines on myocardial revascularization. Eur Heart J 2010; 31: 2501-2555
- 5 Werner GS et al. The functional reserve of collaterals supplying long-term chronic total coronary occlusions in patients without prior myocardial infarction. Eur Heart J 2006; 27: 2406-2412
- 6 Sirnes PA et al. Improvement in left ventricular ejection fraction and wall motion after successful recanalization of chronic coronary occlusions. Eur Heart J 1998; 19: 273-281
- 7 Warren RJ, Black AJ, Valentine PA et al. Coronary angioplasty for chronic total occlusion reduces the need for subsequent coronary bypass surgery. Am Heart J 1990; 120: 270-274
- 8 Kirschbaum SW et al. Evaluation of left ventricular function three years after percutaneous recanalization of chronic total coronary occlusions. Am J Cardiol 2008; 101: 179-185
- 9 Surber R et al. Resting 12-lead electrocardiogram as a reliable predictor of functional recovery after recanalization of chronic total coronary occlusions. Clin Cardiol 2005; 28: 293-297
- 10 Hochman JS et al. Coronary intervention for persistent occlusion after myocardial infarction. N Engl J Med 2006; 355: 2395-2407
- 11 Galassi AR et al. In-hospital outcomes of percutaneous coronary intervention in patients with chronic total occlusion: insights from the ERCTO (European Registry of Chronic Total Occlusion) registry. EuroIntervention 2011; 7: 472-479
- 12 Hannan EL et al. Impact of completeness of percutaneous coronary intervention revascularization on long-term outcomes in the stent era. Circulation 2006; 113: 2406-2412
- 13 Valenti R et al. Impact of complete revascularization with percutaneous coronary intervention on survival in patients with at least one chronic total occlusion. Eur Heart J 2008; 29: 2336-2342
- 14 Werner GS et al. Chronic total coronary occlusions in patients with stable angina pectoris: impact on therapy and outcome in present day clinical practice. Clin Res Cardiol 2009; 98: 435-441
- 15 Grantham JA et al. Chronic total occlusion angioplasty in the United States. JACC Cardiovasc Interv 2009; 2: 479-486
- 16 Farooq V et al. The negative impact of incomplete angiographic revascularization on clinical outcomes and its association with total occlusions: the SYNTAX (Synergy Between Percutaneous Coronary Intervention with Taxus and Cardiac Surgery) trial. J Am Coll Cardiol 2013; 61: 282-294
- 17 Widimsky P et al. One-year coronary bypass graft patency: a randomized comparison between off-pump and on-pump surgery angiographic results of the PRAGUE-4 trial. Circulation 2004; 110: 3418-3423
- 18 Werner GS et al. Contemporary success and complication rates of percutaneous coronary intervention for chronic total coronary occlusions: results from the ALKK quality control registry of 2006. EuroIntervention 2010; 6: 361-366
- 19 Morino Y 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
- 20 Laskey WK et al. Volume-to-creatinine clearance ratio: a pharmacokinetically based risk factor for prediction of early creatinine increase after percutaneous coronary intervention. J Am Coll Cardiol 2007; 50: 584-590
- 21 Martin-Yuste V et al. Factors determining success in percutaneous revascularization of chronic total coronary occlusion: multidetector computed tomography analysis. Rev Esp Cardiol (Engl Ed) 2012; 65: 334-340
- 22 Ueno K et al. Effect of preoperative evaluation by multidetector computed tomography in percutaneous coronary interventions of chronic total occlusions. Int J Cardiol 2012; 156: 76-79
- 23 Valenti R et al. Predictors of reocclusion after successful drug-eluting stent-supported percutaneous coronary intervention of chronic total occlusion. J Am Coll Cardiol 2013; 61: 545
- 24 Reifart N. The parallel wire technique for chronic total occlusions, 1995: p. personal communication, Interventional Course Frankfurt.
- 25 Godino C et al. Coronary chronic total occlusions: mid-term comparison of clinical outcome following the use of the guided-STAR technique and conventional anterograde approaches. Catheter Cardiovasc Interv 2012; 79: 20-27
- 26 Werner GS et al. Multicentre experience with the BridgePoint devices to facilitate recanalisation of chronic total coronary occlusions through controlled subintimal re-entry. EuroIntervention 2011; 7: 192-200
- 27 Kato M et al. The necessity of follow-up for radiation skin injuries in patients after percutaneous coronary interventions: radiation skin injuries will often be overlooked clinically. Acta Radiol 2012; 53: 1040-1044
- 28 Stone GW et al. Percutaneous recanalization of chronically occluded coronary arteries: a consensus document: part II. Circulation 2005; 112: 2530-2537
- 29 Colmenarez HJ et al. Efficacy and safety of drug-eluting stents in chronic total coronary occlusion recanalization: a systematic review and meta-analysis. J Am Coll Cardiol 2010; 55: 1854-1866