Castaldi Gianluca, Benedetti Alice, Zivelonghi Carlo, Scott Benjamin, Wilgenhof Adriaan, Convens Carl, Verheye Stefan, Vermeersch Paul, Agostoni Pierfrancesco
Hartcentrum Ziekenhuis Netwerk Antwerpen Middelheim, Antwerp, Belgium.
Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands.
Minerva Cardiol Angiol. 2023 Mar 13. doi: 10.23736/S2724-5683.23.06293-2.
Percutaneous coronary intervention (PCI) of coronary chronic total occlusion (CTO PCI) is one of the most challenging but rewarding procedures in the portfolio of interventional cardiologists. Several challenges, however, still must be overcome and many questions need to be answered. After coronary artery bypass graft (CABG), disease of the conduits and concomitant progression of atherosclerotic disease to CTO of the subtended native coronary vessels are common and associated with onset of new anginal symptoms and worsening of the prognosis. Which is the best strategy for these post-CABG CTOs? Furthermore, what is the role of physiology in the setting of CTO PCI? In the last decades, many researchers tried to demystify the complex maze but technical limitations and the demanding procedure itself, for both the patient and the operator, do not allow extensive investigation of its impact on clinical practice. Can we enhance periprocedural planning of CTO PCI with a more tailored and multidimensional evaluation? Analysis of coronary computed tomography angiography (CCTA) scans is getting more and more incorporated into the clinical routine and training of interventional cardiologists but mainly focuses on structural valvular disease. Nevertheless, with the appropriate expertise, a lot of information can be derived for coronary intervention to improve procedural planning and potentially outcomes. Finally, in the era of drug-eluting stent, is there a place for strategies that minimize metal implantation in the coronaries to further reduce late-onset adverse events in CTO PCI? This approach could be attractive in CTOs due to the higher risk of target vessel failure and revascularization shown in literature but, at the same time, more challenging due to the histological and anatomical complexity of the disease. In this review, we aim to tackle these questions and concomitantly provide a vision of potential future application of new techniques and technology in CTO PCI that could allow further advancement in this field.
冠状动脉慢性完全闭塞病变的经皮冠状动脉介入治疗（CTO PCI）是介入心脏病学家所面临的最具挑战性但也最有价值的手术之一。然而，仍有一些挑战必须克服，许多问题需要解答。冠状动脉旁路移植术（CABG）后，移植血管病变以及所支配的自身冠状动脉血管粥样硬化疾病进展为慢性完全闭塞很常见，并与新的心绞痛症状发作和预后恶化相关。对于这些CABG术后的慢性完全闭塞病变，最佳策略是什么？此外，生理学在CTO PCI中的作用是什么？在过去几十年里，许多研究人员试图解开这个复杂的谜团，但技术限制以及该手术本身对患者和操作者的高要求，使得无法广泛研究其对临床实践的影响。我们能否通过更具针对性和多维的评估来加强CTO PCI的围手术期规划？冠状动脉计算机断层扫描血管造影（CCTA）扫描分析越来越多地融入介入心脏病学家的临床常规和培训中，但主要集中在结构性瓣膜疾病上。然而，凭借适当的专业知识，可以获得许多用于冠状动脉介入治疗的信息，以改善手术规划并潜在地改善治疗结果。最后，在药物洗脱支架时代，是否存在将冠状动脉内金属植入最小化的策略，以进一步减少CTO PCI中的迟发性不良事件？由于文献中显示的靶血管失败和血运重建风险较高，这种方法在慢性完全闭塞病变中可能具有吸引力，但同时，由于该疾病的组织学和解剖学复杂性，也更具挑战性。在本综述中，我们旨在解决这些问题，并同时展望新技术和技术在CTO PCI中的潜在未来应用，这可能会推动该领域的进一步发展。
