Chronic total occlusions are occluded for at least 3 months with no signs of antegrade blood flow (TIMI 0 flow). Successful recanalization improves symptoms as well as left ventricular ejection fraction and prognosis of these patients. Cardiac magnetic resonance imaging is helpful to determine viable myocardium in the area of the occluded coronary artery. For antegrade techniques (parallel wire, seesaw technique, anchor wire, anchor balloon) retrograde angiography is important to visualize the target vessel distal of the occlusion. Antegrade techniques in combination with retrograde techniques (CART, reverse CART) allow high success rates up to 90%. Drug-eluting stents should be implanted in order to minimize the need for repeat revascularization.
Kernaussagen
Chronische Koronarverschlüsse sind ein häufiger Befund einer Koronarangiographie. Vorhandene Kollateralen können unter Belastung eine ausreichende Perfusion nur selten aufrechthalten.
Die Indikation zur Rekanalisation sollte gestellt werden, wenn es gilt, die Symptome zu lindern, die Ischämie zu verringern und die linksventrikuläre Pumpfunktion und Prognose zu verbessern.
Eine kardiale Magnetresonanztomografie erlaubt die valide Beurteilung, ob vitales Myokard vorliegt.
Die Rekanalisation setzt spezielle Techniken voraus, welche antegrad und retrograd zum Einsatz kommen. Eine sorgfältige Planung der Strategie mit Auswahl des Führungskatheters, Mikrokatheters und Wechsel der Führungsdrähte erhöht die Wahrscheinlichkeit auf Erfolg. Aufgrund der Komplexität und sehr guten Langzeitresultate sollten ausnahmslos DES neuerer Generation eingesetzt werden.
Literatur
1
Christofferson R D, Lehmann K G, Martin G V et al.
Effect of chronic total coronary occlusion on treatment strategy.
Am J Cardiol.
2005;
95
1088-1091
2
Abbott J D, Kip K E, Vlachos H A et al.
Recent trends in the percutaneous treatment of chronic total coronary occlusions.
Am J Cardiol.
2006;
97
1691-1696
3
Werner G S, Hochadel M, Zeymer U 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
4
Sianos G, Barlis P, Di Mario C et al.
EuroCTO Club. European experience with the retrograde approach for the recanalisation of coronary artery chronic total occlusions. A report on behalf of the euroCTO club.
EuroIntervention.
2008;
4
84-92
5
Serruys P W, Morice M C, Kappetein A P et al.
SYNTAX Investigators. Percutaneous coronary intervention versus coronary-artery bypass grafting for severe coronary artery disease.
N Engl J Med.
2009;
360
961-972
6
Werner G S, Surber R, Ferrari M 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
7
Olivari Z, Rubartelli P, Piscione F et al.
TOAST-GISE Investigators. Immediate results and one-year clinical outcome after percutaneous coronary interventions in chronic total occlusions: data from a multicenter, prospective, observational study (TOAST-GISE).
J Am Coll Cardiol.
2003;
41
1672-1678
8
Chung C M, Nakamura S, Tanaka K et al.
Effect of recanalization of chronic total occlusions on global and regional left ventricular function in patients with or without previous myocardial infarction.
Catheter Cardiovasc Interv.
2003;
60
368-374
9
Sirnes P A, Myreng Y, Mølstad P 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
10
Werner G S, Emig U, Bahrmann P et al.
Recovery of impaired microvascular function in collateral dependent myocardium after recanalisation of a chronic total coronary occlusion.
Heart.
2004;
90
1303-1309
11
Nakamura S, Muthusamy T S, Bae J H et al.
Impact of sirolimus-eluting stent on the outcome of patients with chronic total occlusions.
Am J Cardiol.
2005;
95
161-166
12
Hombach V, Grebe O, Merkle N et al.
Sequelae of acute myocardial infarction regarding cardiac structure and function and their prognostic significance as assessed by magnetic resonance imaging.
Eur Heart J.
2005;
26
549-557
13
Baks T, van Geuns R J, Duncker D J et al.
Prediction of left ventricular function after drug-eluting stent implantation for chronic total coronary occlusions.
J Am Coll Cardiol.
2006;
47
721-725
14
Kirschbaum S W, Baks T, van den Ent M et al.
Evaluation of left ventricular function three years after percutaneous recanalization of chronic total coronary occlusions.
Am J Cardiol.
2008;
101
179-185
15
Wagner A, Mahrholdt H, Holly T A et al.
Contrast-enhanced MRI and routine single photon emission computed tomography (SPECT) perfusion imaging for detection of subendocardial myocardial infarcts: an imaging study.
Lancet.
2003;
361
374-379
16
Suero J A, Marso S P, Jones P G et al.
Procedural outcomes and long-term survival among patients undergoing percutaneous coronary intervention of a chronic total occlusion in native coronary arteries: a 20-year experience.
J Am Coll Cardiol.
2001;
38
409-414
17
Hoye A, van Domburg R T, Sonnenschein K, Serruys P W.
Percutaneous coronary intervention for chronic total occlusions: the Thoraxcenter experience 1992–2002.
Eur Heart J.
2005;
26
2630-2636
18
Valenti R, Migliorini A, Signorini U 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
19
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
20
Safley D M, House J A, Marso S P et al.
Improvement in survival following successful percutaneous coronary intervention of coronary chronic total occlusions: variability by target vessel.
JACC Cardiovasc Interv.
2008;
1
295-302
21
Claessen B E, Hoebers L P, van der Schaaf R J et al.
Prevalence and impact of a chronic total occlusion in a non-infarct-related artery on long-term mortality in diabetic patients with ST elevation myocardial infarction.
Heart.
2010;
96
1968-1972
22
Guidelines on myocardial revascularization: The Task Force on Myocardial Revascularization of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS).
Eur Heart J.
2010;
31
2501-2555
23
Werner G S, Diedrich J, Scholz K H et al.
Vessel reconstruction in total coronary occlusions with a long subintimal wire pathway: use of multiple stents under guidance of intravascular ultrasound.
Cathet Cardiovasc Diagn.
1997;
40
46-51
24
Rathore S, Terashima M, Suzuki T.
Value of intravascular ultrasound in the management of coronary chronic total occlusions.
Catheter Cardiovasc Interv.
2009;
4
873-878
25
Colmenarez H J, Escaned J, Fernández C 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
26
Werner G S, Krack A, Schwarz G et al.
Prevention of lesion recurrence in chronic total coronary occlusions by paclitaxel-eluting stents.
J Am Coll Cardiol.
2004;
44
2301-2306
27
Ge L, Iakova I, Sangiorgi G M et al.
Immediate and mid-term outcomes of sirolismus-eluting stent implantation for chronic total occlusions.
Eur Heart J.
2005;
26
1056-1062
29
Suttorp M J, Laarman G J, Rahel B M et al.
Primary stenting of totally occluded native coronary arteries II (PRISON II).
Circulation.
2006;
114
921-928
30
Stone G W, Rizvi A, Newman W et al.
SPIRIT IV Investigators Everolimus-eluting versus paclitaxel-eluting stents in coronary artery disease.
N Engl J Med.
2010;
362
1663-1674
31
Kedhi E, Joesoef K S, McFadden E et al.
Second-generation everolimus-eluting and paclitaxel-eluting stents in real-life practice (COMPARE): a randomised trial.
Lancet.
2010;
375
201-209
33
Wöhrle J, Werner G S.
Paclitaxel-Coated Balloon With Bare-metal Stenting in Patients With Chronic Total Occlusions in Native Coronary Arteries.
in press
34
Wöhrle J, Birkemeyer R, Markovic S et al.
Prospective randomised trial evaluating a paclitaxel-coated balloon in patients treated with endothelial progenitor cell capturing stents for de novo coronary artery disease.
Heart.
2011;
97
1338-1342
