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«Restoration of Antegrade Blood Flow in Chronic Coronary Oclcusions: Technique, Early and Late Results»
RECANALIZATION OF CHRONICALLY OCCLUDED CORONARY ARTERIES AND GRAFTS
R. Simon (Kiel, Germany)
Abstract not submitted.
ENDOVASCULAR REVASCULARIZATION OF CHRONICALLY OCCLUDED CORONARY ARTERIES
D.G. losseliani, M.V. Yanitzkaya, P.Yu. Lopotovsky (Moscow)
Purpose of the study: the evaluation of the effectiveness of PTCA in patients with chronically occluded coronary arteries.
Material and methods: the study enrolled 292 patients who underwent successful mechanical recanalization and PTCA of chronically occluded coronary arteries from October 1997 to September 2004. 157 (53,8%) patients (Group 1) underwent PTCA with stenting, the remaining 135 (46,2%) patients (Group 2) - only PTCA.
There were no significant differences between the studied groups as for the essential clinical, laboratory and angiographic data. In Group 1 the procedure was carried out on the LAD in 84 (53,5%) cases, in the RCA - in 43 (27,4%), on the CxB - in 25 (15,9%), on other arteries - in 5 (3,3%) cases. In Group 2 the procedure was carried out on the LAD in 78 (57,8%) cases, on the RCA - b 28 (20,7%), on the CxB - in 20 (14,8%), on other arteries -in 9 (6,7%) cases. Endovascular procedures resulted in stabilization of the state and the relief of angina attacks in all patients. There were no in-hospital mortality, serious cardiac events, acute myocardial infarction (AMI).
Results: In the long-term follow-up (mean, 8,4 ±1,7 months) all patients underwent repeated in-hospital examination. There was no late mortality or repeated AMI.
In Group 1 satisfactory results of the procedures were preserved in 63,1% of cases, restenosis was revealed in 14,6%, reocclusion - in 22,3% of cases. In Group 2 satisfactory results of the procedures were preserved in 37,8% of patients, restenosis was revealed in 40,7%, reocclusion - in 21,5% of patients.
At control examination 43,6% and 53,3% of patients, respectively, were angina-free.
Conclusions: in long-term follow-up (about half a year after the procedure) the blood flow restored with endovascular methods persisted in about two thirds of patients. When PTCA is combined with stenting for the restoration of blood flow, the vessel's lumen at the site of procedure is not subject to significant changes (restenosis and reocclusion) reliably more often than with PTCA alone. The preservation of antegrade blood flow in those vessels the anginal attacks are significantly reduced or totally disappear.
RECANALIZATION (ANGIOPLASTY AND STENTING)
OF CHRONIC CORONARY OCCLUSIONS:
TACTICS OF INTERVENTION, IMMEDIATE AND LATE RESULTS
A.M. Babunashvili, D.P.Dundua, D.S. Kartashov,
Z.A.Kavteladze (Moscow)
Objective: estimation of immediate and late results of recanalization in chronic coronary occlusions.
Material: angioplasty results were analyzed in 86 patients with occluded coronary arteries. Lumen of one occluded coronary artery was restored in 83 patients, lumens of 2 occluded coronary arteries
- in 3 patients. A total of 89 occluded coronary artery segments underwent surgical intervention: 54 - in left anterior descending coronary artery (LAD), 28 - in right coronary artery (RCA), 6 - in circumflex coronary artery (CA). In one case the lumen of occluded left main coronary artery was restored. The length of 46 occluded segments was 2 cm or less, the length of 43 segments - more than
2 cm. Eight segments were occluded from the ostium (all of them were located in the LAD); 52 occluded segments were located in the proximal portions of arteries, 17 - in the middle portions and 12
- in distal portions. Classic "wedge-shaped" occlusion stump was detected only in 48 cases (53.9%), distal post-occlusion arterial bed was clearly visualized through the collateral vessels of grade II and
III in 60 cases (67.4%). Grade I collateral vessels were observed in 19 cases (21.3%), and in the 10 remaining cases (11.3%) it was difficult to assess distal arterial bed due to low collateral blood filling.
Results: procedure success (remaining stenosis less than 20%, blood flow TIMI III) was achieved in 71 segments (79.8%). Technical failure was observed in 13 cases (14.6%), and in 5 patients (5.6%) complications developed (2 artery perforations resulted in hemopericardium, though there was no need for pericardiocentesis or surgical intervention; 2 acute thromboses of recanalized segment without clinical and ECG-manifestations, and 1 non-Q-wave acute myocardial infarction).
There were no fatal outcomes. Stenting was performed in 42 out of 71 recanalized segments (59.2%), and in 29 segments (40.8%) only balloon dilatation was conducted. A total of 68 stents were implanted in 42 segments (on the average 1.6 stents for 1 occluded segment). In 10 out of 13 cases of technical failure "bridge collaterals" were observed, in 11 cases there was no well-defined "wedge-shaped" stump, in 12 cases the occlusion duration was more than 1 year, and the length of occlusion was more than 2 cm in 10 segments. In both cases of arterial perforation the occlusion duration was more than 2 years.
Late results were evaluated in 41 (63.1 %) out of 65 patients with successful immediate results of surgical intervention. Annual survival was 98.5%. Control coronary angiography was performed in 31 patients. Angiographic restenosis was observed in 10 cases (32.2%), 21 patients had no evidence of restenosis (67.8%). Clinical symptoms of angina recurrence were observed in 8 (19.5%), out of 41 patients, it was 1.6 fold less than angiographic restenosis rate.
Repeated myocardial revascularization (repeated angioplasty in all cases) was performed in 5 patients (12.2%). Stenting was performed in 20 (83.3%) out of 24 segments without angiographic restenosis, and in 5 out of 10 segments with restenosis.
Summary: In case the occluded coronary artery supplies the biggest part of viable myocardium (myocardium with intact contractility or "hibernating" myocardium), recanalization and angioplasty of the occluded segments with occlusion duration of one year or less, is considered to be clinically effective procedure regarding both immediate and late results.
Stenting of recanalized segments improves late results of intervention. Comparative analysis of PTCA and stenting results allows us to make a conclusion that stenting is an obligatory procedure after recanalization and angioplasty of the occluded artery.
CLINICAL EFFECTIVENESS OF MYOCARDIAL REVASCULARIZATION IN CHRONIC CORONARY OCCLUSIONS
A.V.Protopopov, T.A. Kochkina, E.P.Konstantinov,
D.P. Stoliarov, Ya. O. Fedchenko, P.G. Gavrikov (Krasnoyarsk)
Objective: evaluation of dynamics of clinical parameters in patients with chronic coronary occlusions after catheter interventions.
Materials and methods: clinical results were evaluated in 225 patients with successfully performed recanalization of chronic coronary occlusions at follow-up of 36 months after the procedure. Recanalization of left anterior descending artery was performed in 105 patients, right coronary artery - in 90 patients, left circumflex coronary artery - in 30 patients. Occlusion duration was 3-48 months. Stenting of occluded segment was performed in 85% of cases.
Results: recanalizations of chronic occlusions, especially interventions on the left anterior descending artery and right coronary artery, were associated with positive clinical effect. Functional class of angina reduced from III to 0-I, LVEF increased by 8-20%, and exercise tolerance increased on the evidence of exercise tests results. After the follow-up period of 36 months restenosis of operated segment was observed in 18% of cases in patients with recanalization of left anterior descending artery, in 15.5% of recanalizations of right coronary artery, and in 20% of recanalizations of left circumflex coronary artery (metallic stents were used).
Conclusion: myocardial revascularization in chronic coronary occlusions is an effective method of therapy in patients with coronary artery disease and is associated with improvement of basic clinical parameters.
IMMEDIATE RESULTS OF ENDOVASCULAR TREATMENT OF CHRONIC CORONARY OCCLUSIONS
OGY
ABSTRACTS OF THE SECOND RUSSIAN CONGRESS OF INTERVENTIONAL CARDIOANGIOL-
A.P. Perevalov, O.S. Poletaev, K.B. Klestov (Ijevsk)
Since January 2000, 29 recanalization procedures on chronic coronary occlusions were performed in 27 patients aged from 40 to 79 years. Eleven patients had right coronary artery occlusion, 2 - left main coronary artery occlusion, 9 - occlusion of left anterior descending artery, 3 - of obtuse marginal artery, 4 - of left circumflex coronary artery and 1 - of posterior descending coronary artery. We managed to restore the patency of 21 arteries (immediate success in 72.41% of cases). Stenting of these arterial segments was performed in 12 out of 21 cases (in one case 2 stents were implanted), percutaneous transluminal coronary angioplasty alone with satisfactory angiographic result was performed in 9 cases. At the beginning of procedure guidewires "STABILIZER", "SQFT", and "SUPERSQFT" were used in all cases; and then guidewire "SCHINQBI" was used. The characteristics of recanalization in chronic occlusions are long duration of surgical procedure and fluoroscopy, large consumption of contrast agent that certainly leads to limited usage of this procedure in debilitated patients and patients with critical status.
Recanalization attempts were stopped after 90 minutes of X-ray exposure, contrast agent consumption up to 400 ml ("Qmnipak-350","Nicomed").
Conclusion: our experience in endovascular recanalization of chronic coronary occlusions shows that this method can be used in clinical practice. The most important criteria of patient selection for coronary artery recanalization are occlusion duration (up to 3 months), presence of impaired vessel stump, presence of lateral branch at the occlusion region.
FOLLOW-UP OF STENTING FOR CORONARY OCCLUSIONS
S.A. Biriukov, A.M. Babunashvili, P.G. Shwalb, V.V. Kazakov,
G.N. Lazareva (Riazan)
Purpose: to assess the long-term efficacy of stenting for recanalization of coronary artery occlusion.
Materials and methods: we analyzed the results of successful recanalization performed for chronic occlusion of coronary arteries in 68 patients (76 segments) between 1996 and 2004. Mean age of patients was 49±9 years. All patients had FC II-III angina. In 18 patients occlusion was accompanied by stenoses of other large coronary arteries and was analyzed isolated lesion only in 8 patients. The ejection fraction (EF) was above 50% in 54 patients (79.4%), between 40 and 50% - in 14 patients (20.6%). Mean duration of occlusion was 7±4 months.
Long-term results were assessed in 64 (94.1%) patients, of these 48 patients (75%) underwent repeated coronary angiography, the remaining 16 patients (25%) were examined using questionnaire and stress testing. Mean long-term follow-up after coronary stenting was 11.4 months. Maximum follow-up was 63 months.
Results: in 90.8% of patients after balloon dilatation at the site of coronary artery recanalization we found intimal dissection and residual stenosis over 50% (in a total of 69 occlusions out of 76). Only in 7 patients (9.2%) there were minor angiographic findings after balloon dilatation (no dissection, and residual stenosis below 50%). Complications of dissection, which doubtlessly required stenting, were found in 27.4% of cases, in 2.6% of cases balloon dilation was followed by acute occlusion at the site of recanalization.
Angiographic restenosis was observed in 11 (22.9%) cases out of 48, reocclusion was revealed in one segment (2.1%). The highest rate of restenosis in the middle LAD portion was 39.3%. Restenosis was twice more common in arteries <3 mm in diameter compared to arteries above 3 mm in diameter.
In the long-term period the left ventricular EF increased from 4 to 16%. In 46 patients (67.6%) no further symptoms of angina occurred. FC I angina was detected in 4 (5.9%) patients, FC II angina - in 6 (8.8%), and FC III angina - in 8 (12.5%) respectively.
Conclusions: stenting improves the results of balloon angioplasty after recanalization of coronary arteries. Independent predictors of long-term success after recanalization and stenting for coronary artery occlusion are: arterial diameter and the length of occlusion at the site of stenting.
M.V. Demina, I.Yu. Bravve (Novosibirsk)
Objective: analysis of anatomo-morphological features of coronary occlusions that are potentially dangerous due to a risk of artery perforation during percutaneous recanalization.
Materials and methods: percutaneous coronary intervention (PCI) due to coronary occlusions was performed on 139 occluded segments in 137 patients. One hundred and sixty four attempts of guidewire recanalization were conducted. Coronary occlusion were located in the left anterior descending artery, right coronary artery and circumflex artery. Most frequently interventions were performed in the left anterior descending artery region - 76 cases (54.7%). Forty six PCI (33.1%) were performed on RCA occlusions. Recanalization of circumflex artery was performed in 17 (12.2%) cases. The rate of perforation development was analyzed considering various morphologic features of occlusion: length of occluded segment,"age" of occlusion, location of lesion, bridging collaterals and antegrade blood flow.
Results: coronary artery perforation was observed in 9 cases that averaged to 5.5% of the number of guidewire recanalization attempts. All perforations were of grade I (slight amount of contrast outside the vessel) or II (large amount of contrast outside the vessel) and did not lead to cardiac tamponade. Eight occlusions were located in the right coronary artery. The occlusion duration was more than
3 months in 4 cases (45%). Anatomic features of occluded arteries, in which the perforation occurred, were as follows: in 8 out of 9 occluded segments (89%) the occlusion length was over 15 mm, bridging collaterals were observed in 4 cases (45%).
Conclusion: Risk of coronary artery perforation during recanalization is very high in the presence of following anatomo-morpho-logical features: occlusion location in the right coronary artery in combination with length over 15 mm.
DYNAMICS OF GENERAL AND SEGMENTAL CONTRACTILITY OF LEFT VENTRICUALR MYOCARDIUM IN PATIENTS AFTER ENDOVASCULAR REPERFUSION OF CHRONICALLY OCCLUDED CORONARY ARTERY
P.Yu. Lopotovsky, S.P. Semitko, M.V. Yanitzkaya (Moscow)
Aims and purposes: to study the influence of endovascular restoration of the blood flow in chronically occluded coronary arteries on left ventricular function.
Material and methods: the study enrolled 115 patients who underwent successful mechanical recanalization of chronically occluded coronary artery with subsequent PTCA and stenting. In 62 cases the procedures was performed on the LAD, in 23 - on the CxB, in 30 - on the RCA. All patients were re-examined in 6,7±1,8 months.
Results: control coronary angiography revealed preserved antegrade blood flow in 93 (75,6%) patients, in 29 (23,6%) patients the vessel was re-occluded. In the whole studied group left ventricular ejection fraction (LVEF) increased from 56,29±1,35% to 59,76±1,34% (p<0,02). With this the greatest increase of LVEF was seen in the group of patients withour significant changes in the artery, submitted to endovascular procedure (from 58,70±1,14% to 61,89±1,80%; p<0,02). LVEF in patients with reocclusion of the target artery didn't significantly increase. The analysis of segmental contractility revealed that the increase of total LVEF occurs at the expense of segments that received blood supply from the coronary artery with preserved blood flow.
Conclusions: the restoration of the blood flow with PTCA in chronically occluded coronary arteries improves general and segmental function of the left ventricle in the long-term follow-up. This effect was seen only in cases of antegrade blood flow preservation by the moment of control examination in the long-term follow-up.
ANATOMICAL AND MORPHOLOGICAL ANALYSIS OF THE CASES OF CORONARY ARTERY PERFORATION OCCURRED DURING RECANALIZATION
V.I. Ganiukov, A.A. Shilov, N.I. Sussoev, I.N. Shigantzov,
ABSTRACTS OF THE SECOND RUSSIAN CONGRESS OF INTERVENTIONAL CARDIOANGIOLOGY (№ 7, 2005)
RUSSIA, MOSCOW, MARCH 28-30, 2005
