Keulards D C J, Vlaar P J, Wijnbergen I, Pijls N H J, Teeuwen K
Catharina Hospital, Eindhoven, The Netherlands.
Eindhoven University of Technology, Eindhoven, The Netherlands.
Neth Heart J. 2021 Jan;29(1):22-29. doi: 10.1007/s12471-020-01470-6.
Studies performed in the last two decades demonstrate that after successful percutaneous coronary intervention (PCI) of a chronically occluded coronary artery, the physiology of the chronic total occlusion (CTO) vessel and dependent microvasculature does not normalise immediately but improves significantly over time. Generally, there is an increase in fractional flow reserve (FFR) in the CTO artery, a decrease in collateral blood supply and an increase in FFR in the donor artery accompanied by an increase in blood flow and decrease in microvascular resistance in the myocardium supplied by the CTO vessel. Analogous to these physiological changes, positive remodelling of the distal CTO artery also occurs over time, and intravascular imaging can be helpful for analysing distal vessel parameters. Follow-up coronary angiography with physiological measurements after several weeks to months can be helpful and informative in a subset of patients in order to decide upon the necessity for treatment of residual coronary artery stenosis in the vessel distal to the CTO or in the contralateral donor artery, as well as in deciding whether stent optimisation is indicated. We suggest that such physiological guidance of CTO procedures avoids unnecessary overtreatment during the initial procedure, guides interventions at follow-up, and improves our understanding of what PCI in CTO means.
过去二十年进行的研究表明，在对慢性闭塞冠状动脉成功进行经皮冠状动脉介入治疗（PCI）后，慢性完全闭塞（CTO）血管及其相关微血管的生理功能不会立即恢复正常，但会随着时间显著改善。一般来说，CTO动脉的血流储备分数（FFR）增加，侧支血供减少，供血动脉的FFR增加，同时CTO血管供血的心肌血流量增加，微血管阻力降低。与这些生理变化类似，CTO动脉远端也会随着时间发生正向重塑，血管内成像有助于分析远端血管参数。在数周或数月后进行的随访冠状动脉造影及生理测量，对部分患者可能是有帮助且能提供信息的，有助于决定是否有必要治疗CTO远端血管或对侧供血动脉中的残余冠状动脉狭窄，以及是否需要进行支架优化。我们认为，这种CTO手术的生理指导可避免初始手术期间的不必要过度治疗，指导随访时的干预，并增进我们对CTO中PCI意义的理解。
