Vaduganathan Muthiah, Kornowski Ran, Vaknin-Assa Hana, Greenberg Gabriel, Bental Tamir, Lev Eli I, Assali Abid R
aDepartment of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA bDepartment of Cardiology, Rabin Medical Center, Petah-Tikva, Tel-Aviv University, Tel-Aviv, Israel.
J Cardiovasc Med (Hagerstown). 2016 Sep;17(9):673-9. doi: 10.2459/JCM.0000000000000231.
This 'real-world' investigation attempted to determine the long-term prognoses of patients who have undergone successful revascularization of chronic total occlusion (CTO) lesions.
All consecutive unselected patients from January 2006 to June 2011, undergoing stenting for CTO (n = 272), were retrospectively identified through an institutional registry. Procedural failure was defined as final diameter stenosis greater than 30% or postdilatation thrombolysis in myocardial infarction flow less than 3. Outcomes were assessed based on stenting type [bare metal stent (BMS), drug-eluting stent (DES), or mixed] in the successful procedural cohort. Multiple logistic regression analyses were used to account for known baseline cardiovascular risk imbalances. The primary endpoint was 2-year target vessel revascularization.
Overall procedural failure occurred in 55 (20.2%) patients presenting with CTO lesions. Failed revascularization was independently associated with multivessel disease, lesion lengths greater than 15 mm, tortuous segments, and presence of calcifications. Major complications included coronary dissection (10%) and perforation (2%). Of the successful procedures, 141 (64%) underwent pure DES, 46 (21%) pure BMS, and 34 (15%) mixed stenting. At 2-year follow-up, fewer patients in the DES group required repeat revascularization compared to the mixed stenting group (6 vs. 26%; P = 0.002). Mixed stenting was an independent predictor of long-term target vessel revascularization (adjusted odds ratio 2.1, 95% confidence interval 1.1-4.1, P = 0.02) compared to DES.
Failed revascularization of CTO lesions occurs in a fifth of patients and appears to be associated with complex vessel anatomy. Our data suggest that DES use in this setting are associated with improved 2-year clinical endpoints compared with pure BMS or mixed stenting approaches.
本“真实世界”研究旨在确定慢性完全闭塞（CTO）病变成功血运重建患者的长期预后。
通过机构登记回顾性确定2006年1月至2011年6月期间所有连续入选的接受CTO支架置入术的患者（n = 272）。手术失败定义为最终直径狭窄大于30%或扩张后心肌梗死溶栓血流小于3级。在成功的手术队列中，根据支架类型[裸金属支架（BMS）、药物洗脱支架（DES）或混合支架]评估结果。采用多元逻辑回归分析来解释已知的基线心血管风险不平衡。主要终点是2年靶血管血运重建。
55例（20.2%）CTO病变患者出现总体手术失败。血运重建失败与多支血管病变、病变长度大于15mm、迂曲节段和钙化的存在独立相关。主要并发症包括冠状动脉夹层（10%）和穿孔（2%）。在成功的手术中，141例（64%）接受了单纯DES，46例（21%）接受了单纯BMS，34例（15%）接受了混合支架置入术。在2年随访时，与混合支架组相比，DES组需要再次血运重建的患者更少（6%对26%；P = 0.002）。与DES相比，混合支架置入术是长期靶血管血运重建的独立预测因素（调整后的优势比为2.1，95%置信区间为1.1 - 4.1，P = 0.02）。
五分之一的CTO病变患者血运重建失败，似乎与复杂的血管解剖结构有关。我们的数据表明，在这种情况下使用DES与单纯BMS或混合支架置入术相比，2年临床终点有所改善。
