血管内超声指导的真腔寻径与跟踪技术治疗复杂冠状动脉慢性完全闭塞病变的回顾性分析

摘要

Objective: Currently, the major obstacle for treating complex chronic total occlusions (CTO) by percutaneous coronary intervention (PCI) is reaching the true lumen. We reported a novel outcome of intravascular ultrasound guided true lumen seeking and tracking ((IVUS-TST) technique for treating the patients with CTO lesions or the patients with failed PCI. Methods: We retrospectively summarized all patients with CTO lesions treated in our hospital by the same cardiologist from 2013-01-01 to 2013-12-31. CTO is defined as J-CTO Score≥1; successful intervention is defined by angiography or IVUS conifrmed wire reached the remote true lumen or at least ifnished the balloon dilatation. The treatment was divided into 2 groups: Angiography group,n=49 lesions and IVUS-TST group,n=67 lesions. The rates of success and complication were compared and the reasons for failed treatment were analyzed. Results: A total of 140 patients with 148 lesions were studied and 32 patients with 32 simple lesions (J-CTO score<1) were excluded. The rest 108 patients with 116 complex lesions (J-Score=2.18 ± 0.80) were evaluated. There were 98 male and 18 female patients at the age of (56.71 ± 11.89) years. Compared with Angiography group, IVUS-TST group had the higher J-Score (2.33 ± 0.84) vs (1.98 ± 0.69),P=0.019, longer occluded lesion (37.99 ± 22.51) vs (31.43 ± 20.20) mm,P=0.034;IVUS-TST group had the higher trend of PCI success rate 65.7% vs 49.0%,P=0.071, decreased trend of coronary perforation (9.0% vs 18.4%,P=0.136) and slightly decreased dissection of valsalva sinus (0% vs 6.1%,P=0.073). No in-hospital death and no emergent CABG were needed. Multiple regression analysis presented that IVUS-TST (OR=2.756, 95%CI 1.019-7.453, P=0.046) was the independent predictor for elevating the success rate in treating CTO patients. The main cause of failed PCI was the wire entry point to false lumen (43.8%) or fail to re-enter the true lumen (43.8%); While IVUS-TST may better enter the true lumen at the entry point (33.8%) or re-enter the true lumen (35.3%). Conclusion: IVUS-TST is effective for treating the patients with CTO lesions, it is expected to increase the success rate and decrease the severe complications.%目的：目前冠状动脉慢性完全闭塞（CTO）病变经皮冠状动脉介入治疗（PCI），前向或逆向技术的关键和难点均在于使导丝通过病变至远端血管真腔。本研究报道一种血管内超声指导的真腔寻径与跟踪（IVUS-TST）的前向新技术，用于前向治疗复杂CTO病变或介入失败的患者。　　方法：总结2013-01-01至2013-12-31同一介入术者所完成的全部CTO病例，分为造影引导组（n=49）和IVUS-TST组（n=67）两组，对比成功率、并发症率并分析失败原因。复杂CTO病变定义为日本J-CTO评分≥1分。介入成功定义为经对侧造影或血管内超声（IVUS）证实的导丝位于闭塞段远端真腔，至少完成了球囊扩张治疗。　　结果：140例患者148个CTO病变中，去除32例32个简单CTO病变（J-CTO评分<1分，PCI成功率100%）后，共108例患者[男性90例，女性18例，平均年龄（56.71±11.89）岁]的116个复杂CTO病变[J-CTO评分平均为（2.18±0.80）分]纳入分析。与造影引导组相比，IVUS-TST组J-CTO评分显著更高[（2.33±0.84）分vs （1.98±0.69）分，P=0.019]，病变显著更长（37.99±22.51）mm vs （31.43±20.20）mm，P=0.034]，差异均有统计学意义。两组相比，IVUS-TST组较造影引导组PCI成功率有提高趋势（65.7% vs 49.0%，P=0.071）；冠状动脉穿孔（9.0% vs 18.4%， P=0.136）和窦部损伤（0% vs 6.1%，P=0.073）比例也有降低趋势，但差异无统计学意义。所有患者均无住院死亡或行急诊冠状动脉旁路移植手术。多因素回归分析显示，IVUS-TST技术（比值比=2.756，95%可信区间1.019~7.453， P=0.046）是提高复杂CTO介入治疗成功的独立预测因素。复杂CTO介入失败的主要原因为导丝入口即进入假腔（43.8%）或不能再穿入真腔（43.8%）；IVUS-TST技术的优势在于能使导丝从入口直接穿进真腔（33.8%），或引导内膜下导丝再穿入真腔（35.3%）。　　结论：以真腔为目标的IVUS-TST技术是一种有效治疗复杂CTO病变的新方法，可望提高手术成功率，减少严重并发症发生。