Karmpaliotis Dimitri, Karatasakis Aris, Alaswad Khaldoon, Jaffer Farouc A, Yeh Robert W, Wyman R Michael, Lombardi William L, Grantham J Aaron, Kandzari David E, Lembo Nicholas J, Doing Anthony, Patel Mitul, Bahadorani John N, Moses Jeffrey W, Kirtane Ajay J, Parikh Manish, Ali Ziad A, Kalra Sanjog, Nguyen-Trong Phuong-Khanh J, Danek Barbara A, Karacsonyi Judit, Rangan Bavana V, Roesle Michele K, Thompson Craig A, Banerjee Subhash, Brilakis Emmanouil S
From the Center for Interventional Vascular Therapy at New York-Presbyterian Hospital/Columbia University Medical Center, New York (D.K., J.W.M., A.J.K., M.P., Z.A.A., S.K.); Department of Cardiology, VA North Texas Healthcare System and University of Texas Southwestern Medical Center, Dallas (A.K., P.-K.J.N.-T., B.A.D., J.K., B.V.R., M.K.R., S.B., E.S.B.); Department of Cardiology, Henry Ford Hospital, Detroit, MI (K.A.); Department of Cardiology, Massachusetts General Hospital and Harvard Medical School, Boston (F.A.J.); CardioVascular Institute at Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA (R.W.Y.); Lundquist Cardiovascular Institute, Torrance Memorial Medical Center, CA (R.M.W.); Cardiovascular Center, PeaceHealth St. Joseph Medical Center, Bellingham, WA (W.L.L.); Department of Interventional Cardiology, Mid America Heart Institute, Kansas City, MO (J.A.G.); Department of Interventional Cardiology, Piedmont Heart Institute, Atlanta, GA (D.E.K., N.J.L.); Department of Cardiology, Medical Center of the Rockies, Loveland, CO (A.D.); Division of Cardiovascular Medicine, VA San Diego Healthcare System and University of California (M.P., J.N.B.); and Boston Scientific, Natick, MA (C.A.T.).
Circ Cardiovasc Interv. 2016 Jun;9(6). doi: 10.1161/CIRCINTERVENTIONS.115.003434.
We sought to examine the efficacy and safety of chronic total occlusion percutaneous coronary intervention using the retrograde approach.
We compared the outcomes of the retrograde versus antegrade-only approach to chronic total occlusion percutaneous coronary intervention among 1301 procedures performed at 11 experienced US centers between 2012 and 2015. The mean age was 65.5±10 years, and 84% of the patients were men with a high prevalence of diabetes mellitus (45%) and previous coronary artery bypass graft surgery (34%). Overall technical and procedural success rates were 90% and 89%, respectively, and in-hospital major adverse cardiovascular events occurred in 31 patients (2.4%). The retrograde approach was used in 539 cases (41%), either as the initial strategy (46%) or after a failed antegrade attempt (54%). When compared with antegrade-only cases, retrograde cases were significantly more complex, both clinically (previous coronary artery bypass graft surgery prevalence, 48% versus 24%; P<0.001) and angiographically (mean Japan-chronic total occlusion score, 3.1±1.0 versus 2.1±1.2; P<0.001) and had lower technical success (85% versus 94%; P<0.001) and higher major adverse cardiovascular events (4.3% versus 1.1%; P<0.001) rates. On multivariable analysis, the presence of suitable collaterals, no smoking, no previous coronary artery bypass graft surgery, and left anterior descending artery target vessel were independently associated with technical success using the retrograde approach.
The retrograde approach is commonly used in contemporary chronic total occlusion percutaneous coronary intervention, especially among more challenging lesions and patients. Although associated with lower success and higher major adverse cardiovascular event rates in comparison to antegrade-only crossing, retrograde percutaneous coronary intervention remains critical for achieving overall high success rates.
我们试图探讨采用逆向入路进行慢性完全闭塞病变经皮冠状动脉介入治疗的有效性和安全性。
我们比较了2012年至2015年在美国11个经验丰富的中心进行的1301例慢性完全闭塞病变经皮冠状动脉介入治疗中逆向入路与仅正向入路的治疗结果。平均年龄为65.5±10岁，84%的患者为男性，糖尿病患病率高（45%），既往有冠状动脉搭桥手术史的患者比例为34%。总体技术成功率和手术成功率分别为90%和89%，31例患者（2.4%）发生院内主要不良心血管事件。539例（41%）采用逆向入路，要么作为初始策略（46%），要么在正向尝试失败后采用（54%）。与仅采用正向入路的病例相比，逆向入路病例在临床方面（既往冠状动脉搭桥手术患病率分别为48%和24%；P<0.001）和血管造影方面（平均日本慢性完全闭塞病变评分分别为3.1±1.0和2.1±1.2；P<0.001）都明显更复杂，技术成功率较低（85%和94%；P<0.001），主要不良心血管事件发生率较高（4.3%和1.1%；P<0.001）。多变量分析显示，存在合适的侧支循环、不吸烟、无既往冠状动脉搭桥手术史以及左前降支为靶血管与采用逆向入路的技术成功独立相关。
逆向入路在当代慢性完全闭塞病变经皮冠状动脉介入治疗中常用，尤其是在更具挑战性的病变和患者中。尽管与仅正向通过相比成功率较低且主要不良心血管事件发生率较高，但逆向经皮冠状动脉介入治疗对于实现总体高成功率仍然至关重要。
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