何松坚,吴铿,游琼,莫海亮

• 1:广东医学院附属医院心血管内科

摘要(Abstract)：

目的对比研究改良的交替平行技术硬/软导丝组合与经典"升阶梯"导丝技术突破慢性完全闭塞病变(CTO)的有效性、安全性。方法纳入2012年1月至2015年6月拟行经皮冠状动脉介入治疗(PCI)患者120例,随机分为硬/软导丝组合交替平行技术组(Improved组,61例)和经典"升阶梯"导丝技术组(Classic组,59例)。两组患者PCI均采用正向导丝技术,评估指标包括首次突破成功率、失败后再次突破成功率、导丝耗材数、X线暴露时间、对比剂用量,手术并发症,30 d主要不良心血管事件(MACE)及次要不良事件发生率,术前、术后30 d评估NYHA心功能分级、左心室射血分数(LVEF)、6 min步行试验。结果两组患者基线资料及CTO受累血管部位等造影资料比较,差异均无统计学意义(均P>0.05);Improved组患者首次导丝突破成功率(93.4%比77.9%,P=0.016)高于Classic组;经过交换导丝技术后,Improved组累次导丝突破成功率与Classic组比较(95.1%比96.6%,P=0.742),差异无统计学意义;导丝技术成功患者经球囊预扩张,置入药物洗脱支架均成功。Improved组患者导丝耗材数[3.0(2.0,4.0)根比5.0(3.0,7.0)根,P=0.018]、X线暴露时间[(110±65)min比(175±73)min,P=0.024]、对比剂用量[(210±137)ml比(305±148)ml,P=0.017]均少于Classic组,差异有统计学意义;两组患者冠状动脉夹层、感染、穿刺血肿、假性动脉瘤等发生率比较,差异均无统计学意义(均P>0.05);Improved组患者总体不良事件发生率低于Classic组(16.4%比30.5%,P=0.045);两组患者NYHA心功能Ⅰ级(19.7%比11.9%,P=0.062)比较,差异无统计学意义,而Improved组患者NYHA心功能Ⅱ级(45.9%比32.2%,P=0.038)高于Classic组,Ⅲ级(26.3%比37.3%,P=0.047)、Ⅳ级(8.2%比18.6%,P=0.026)低于Classic组;Improved组患者LVEF[(51.5±10.3)%比(47.3±11.4)%,P=0.029]、6 min步行距离[(437±43)m比(376±52)m,P=0.031]均高于Classic组。结论改良的交替平行技术硬/软导丝组合安全性好,突破困难和非常困难CTO的有效性、手术成功率优于经典"升阶梯"导丝技术。

关键词(KeyWords)： 慢性完全闭塞病变;经皮冠状动脉介入治疗;主要不良心血管事件;导丝技术

Abstract:

Keywords:

基金项目(Foundation): 中国科协阳光基金资助项目(608H20140017)

作者(Author): 何松坚,吴铿,游琼,莫海亮

参考文献(References)：

• [1]Ozawa N.A new understanding of chronic total occlution from novel PCI technique that involves a retrograde approach to the right coronary artery via aseptal branch and passing of the guidewire to a guiding catheter on the other side of the lesion.Catheter Cardiovasc Interv,2006,68(6):907-913.
• [2]Arslan U,Balcioglu AS,Timurkaynak T,et a1.The clinical outcomes of percutaneous coronary intervention in chronic total coronary occlusion.Int Heart J,2006,47(6):811-819.
• [3]Prasad A,Rihal CS,Lennon RJ,et al.Trends in outcomes after percutaneous coronary intervention for chronic total occlusions:a25-year experience from the Mayo Clinic.J Am Coll Cardiol,2007,49(15):1611-1618.
• [4]韩雅玲.提高冠状动脉慢性完全闭塞病变介入治疗成功率的几点思考.中华医学杂志,2011,91(14):937-939.
• [5]Etmis C,Boz A,Tholakanahalli V,et al.Asseement of percutaneous coronary intervention on regional and global left ventricular function in patients with chronic total occlusions.Can J Cardiol,2005,21(3):275-280.
• [6]Rathore S,Matsuo H,Terashima M,et al.Procedural and InHospital Outcomes After Percutaneous Coronary Intervention for Chronic Total Occlusions of Coronary Arteries 2002 to 2008:impact of novel guidewire techniques.JACC Cardiovasc Interv,2009,2(6):489-497.
• [7]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(2):213-221.
• [8]Surmely JF,Tsuchikane E,Katoh O,et al.New concept for CTO recanalization using controlled antegrade and retrograde subintimal tracking:the CART technique.J Invasive Cardiol,2006,18(7):334-338.
• [9]温尚煜,孙志奇,王柏颖,等.血管内超声指导前向导丝经假腔再进入真腔技术治疗冠状动脉慢性完全闭塞病变.中国介入心脏病学杂志,2015,23(9):504-507.
• [10]Saito S.Different strategies of retrograde approach in coronary angioplasty for chronic total occlusion.Catheter Cardiovasc Interv,2008,71(1):8-19.
• [11]Mitsudo K,Yamashita T,Asakura Y,et al.Recanalization strategy for chronic total occlusions with tapered and stiff-tip guidewire.The results of CTO new technique for STandard procedure(CONQUEST)trial.J Invasive Cardiol,2008,20(11):571-577.
• [12]Jones DA,Weerackody R,Rathod K,et al.Successful recanalization of chronic total occlusions is associated with improved long-term survival.JACC Cardiovasc Interv,2012,5(4):380-388.
• [13]Sumitsuji S,Inoue K,Ochiai M,et al.Fundamental wire technique and current standard strategy of percutaneous intervention for chronic total occlusion with histopathological insights.JACC Cardiovasc Interv,2011,4(9):941-951.
• [14]于宏颖,段丽敏,黎辉.经桡动脉微导管联合对侧造影技术在冠状动脉慢性闭塞病变介入治疗中的应用.航空航天医学杂志,2011,22(2):142-143.
• [15]陆浩,葛均波.血管内超声在冠状动脉慢性完全闭塞病变行经皮冠状动脉介入治疗中的再评价.中国介入心脏病学杂志,2015,23(9):531-534.