Guiding Principles for Chronic Total Occlusion Percutaneous Coronary Intervention A Global Expert Consensus Document
Guiding Principles for Chronic Total Occlusion Percutaneous Coronary Intervention A Global Expert Consensus Document
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DOI：
10.1161/circulationaha.119.039797
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发表时间：
2019-07-30
期刊：
影响因子：
37.8
通讯作者：
Rinfret, Stephane
中科院分区：
文献类型：
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作者：
Brilakis, Emmanouil S.;Mashayekhi, Kambis;Rinfret, Stephane
由于设备和技术的进步，慢性完全闭塞（CTO）经皮冠状动脉介入治疗（PCI）的结局有所改善。通过全球合作和知识共享，我们确定了7项被广泛接受为CTO-PCI最佳实践的共同原则。1.缺血症状改善是CTO-PCI的主要适应证。2.双重冠状动脉造影和血管造影片的深入和结构化审查（以及冠状动脉计算机断层扫描血管造影，如果可用）是计划和安全执行CTO-PCI的关键。3.微导管的使用对于最佳导丝操作和交换至关重要。4.顺行导丝、顺行分离和折返以及逆行入路都是互补且必要的交叉策略。顺行导丝是最常见的初始技术，而更复杂的CTO通常需要逆行和顺行分离和折返。5.如果最初选择的通过策略失败，则有效变更为替代通过技术可增加最终PCI成功的可能性，缩短手术时间，并降低辐射和造影剂的使用。6.特定的CTO-PCI专业知识和容量以及专用设备的可用性将增加通过成功的可能性，并有助于预防和管理并发症，如穿孔。7.需要特别注意病变准备和支架植入技术，通常需要冠状动脉内成像，以确保最佳支架扩张并最大限度地降低短期和长期不良事件的风险。这些原则已被经验丰富的CTO-PCI术者和中心广泛采用，目前取得了较高的成功率和可接受的并发症发生率。经验不足的临床试验机构的结局不太理想，强调需要更广泛地采用上述7项指导原则沿着，并通过持续的研究、教育和培训开发其他简单安全的CTO穿越和血运重建策略。
Outcomes of chronic total occlusion (CTO) percutaneous coronary intervention (PCI) have improved because of advancements in equipment and techniques. With global collaboration and knowledge sharing, we have identified 7 common principles that are widely accepted as best practices for CTO-PCI. 1. Ischemic symptom improvement is the primary indication for CTO-PCI. 2. Dual coronary angiography and in-depth and structured review of the angiogram (and, if available, coronary computed tomography angiography) are key for planning and safely performing CTO-PCI. 3. Use of a microcatheter is essential for optimal guidewire manipulation and exchanges. 4. Antegrade wiring, antegrade dissection and reentry, and the retrograde approach are all complementary and necessary crossing strategies. Antegrade wiring is the most common initial technique, whereas retrograde and antegrade dissection and reentry are often required for more complex CTOs. 5. If the initially selected crossing strategy fails, efficient change to an alternative crossing technique increases the likelihood of eventual PCI success, shortens procedure time, and lowers radiation and contrast use. 6. Specific CTO-PCI expertise and volume and the availability of specialized equipment will increase the likelihood of crossing success and facilitate prevention and management of complications, such as perforation. 7. Meticulous attention to lesion preparation and stenting technique, often requiring intracoronary imaging, is required to ensure optimum stent expansion and minimize the risk of short- and long-term adverse events. These principles have been widely adopted by experienced CTO-PCI operators and centers currently achieving high success and acceptable complication rates. Outcomes are less optimal at less experienced centers, highlighting the need for broader adoption of the aforementioned 7 guiding principles along with the development of additional simple and safe CTO crossing and revascularization strategies through ongoing research, education, and training.