Jacobs Donald L, Motaganahalli Raghunandan L, Cox Daniel E, Wittgen Catherine M, Peterson Gary J
Division of Vascular Surgery, Department of Surgery, Saint Louis University Hospital, St Louis, Mo., USA.
J Vasc Surg. 2006 Jun;43(6):1291-6. doi: 10.1016/j.jvs.2006.02.051.
The acute technical failure of endovascular treatment of chronic total occlusions (CTOs) is most often due to the inability to re-enter the true lumen after occlusion is crossed in a subintimal plane. This study reports our initial experience with true lumen re-entry devices in the treatment of CTOs.
Patients with treatment of CTOs were identified from our vascular registry. All patients in whom the Pioneer catheter or the Outback catheter were used were also identified from a prospectively maintained separate database of cases in which true lumen re-entry devices were used. We used procedural data from the prospective database and reviewed the medical records. Lesion character and location, access type, location of true lumen re-entry, stent usage, procedural times, and complications, were tabulated.
From August 2003 to December 2004, endovascular techniques were used to treat 87 CTOs in 58 iliac and 29 superficial femoral arteries. In 24 (26%), the true lumen could not be re-entered by using standard catheter and wire techniques. The true lumen was not initially re-entered in 20 (34%) of 58 of treated iliac CTOs and four (13%) of 29 of treated superficial femoral artery CTOs (73% TASC C and D lesions). Intravascular ultrasound-guided true lumen re-entry using the Pioneer catheter (21 CTOs), or fluoroscopic-guided true lumen re-entry using the Outback catheter (3 CTOs) was successful in achieving true lumen re-entry in all cases at the location desired. Total time of re-entry catheter manipulation required to achieve re-entry was <10 minutes and was routinely accomplished in <3 minutes. All occlusions were stented. No cases were converted to open repair. Bleeding from the recanalization and angioplasty site occurred in four patients (15%). It was controlled with use of covered stents in two cases, and resolved after placement of uncovered stents in the other two. No significant bleeding occurred at the sites of true lumen re-entry needle deployment. All occlusions treated with true lumen re-entry devices remain clinically patent at a mean follow-up of 5.8 months.
Endovascular treatment of chronic total occlusions is often limited by the inability to re-enter the true lumen after subintimal crossing of the occluded segment. This occurs more commonly with treatment of iliac occlusions than in superficial femoral artery occlusions. True lumen re-entry catheters are very effective at gaining wire passage back to the true lumen and facilitating successful endovascular treatment of chronic total occlusions that would otherwise require open bypass.
慢性完全闭塞病变（CTO）血管内治疗的急性技术失败最常见的原因是在闭塞段内膜下平面通过后无法重新进入真腔。本研究报告了我们使用真腔重新进入装置治疗CTO的初步经验。
从我们的血管登记处确定接受CTO治疗的患者。还从一个前瞻性维护的单独病例数据库中确定了所有使用先锋导管或背向导管的患者，该数据库记录了使用真腔重新进入装置的病例。我们使用了前瞻性数据库中的手术数据并查阅了病历。将病变特征和位置、入路类型、真腔重新进入的位置、支架使用情况、手术时间和并发症制成表格。
2003年8月至2004年12月，采用血管内技术治疗了58条髂动脉和29条股浅动脉中的87处CTO。在24例（26%）中，使用标准导管和导丝技术无法重新进入真腔。在58例接受治疗的髂动脉CTO中，有20例（34%）最初未能重新进入真腔，在29例接受治疗的股浅动脉CTO中有4例（13%）最初未能重新进入真腔（73%为TASC C和D级病变）。使用先锋导管在血管内超声引导下进行真腔重新进入（21例CTO），或使用背向导管在透视引导下进行真腔重新进入（3例CTO），在所有病例中均成功在所需位置重新进入真腔。实现重新进入所需的重新进入导管操作总时间<10分钟，通常在<3分钟内完成。所有闭塞病变均植入了支架。没有病例转为开放修复。4例患者（15%）在再通和血管成形术部位发生出血。2例使用覆膜支架控制出血，另外2例在植入无覆膜支架后出血停止。在真腔重新进入针置入部位未发生明显出血。使用真腔重新进入装置治疗的所有闭塞病变在平均5.8个月的随访中临床保持通畅。
慢性完全闭塞病变的血管内治疗常常受到在闭塞段内膜下通过后无法重新进入真腔的限制。这种情况在髂动脉闭塞的治疗中比在股浅动脉闭塞的治疗中更常见。真腔重新进入导管在使导丝回到真腔并促进慢性完全闭塞病变的成功血管内治疗方面非常有效，否则这些病变需要进行开放旁路手术。
