Dwiputra Bambang, Tadano Yutaka, Sugie Takuro, Fujita Tsutomu
Department of Cardiovascular Medicine, Sapporo Cardiovascular Clinic, Sapporo Heart Center, North 49, East 16, 8-1, Higashi Ward, 007-0849 Sapporo, Japan.
Department of Cardiology and Vascular Medicine, University of Indonesia-National Cardiovascular Center Harapan Kita, Jl S Parman Kav 87, Jakarta Barat, 11420 DKI Jakarta, Indonesia.
Eur Heart J Case Rep. 2024 Oct 22;8(11):ytae571. doi: 10.1093/ehjcr/ytae571. eCollection 2024 Nov.
Techniques for treating difficult chronic total occlusions (CTOs) have evolved with the discovery of the tip detection-antegrade dissection re-entry (TDADR) guided by intravascular ultrasound (IVUS). This case demonstrates TDADR as a viable bailout in failed subintimal tracking and re-entry (STAR) technique.
A 78-year-old man with stable angina on optimal medical therapy had exertional angina pectoris secondary to a residual CTO lesion of the left circumflex coronary (LCX) artery. Percutaneous coronary intervention was performed for a mid-LCX CTO with a blunt proximal stump where the dissection plane expanded along the main vessel and side branch 2. Due to lack of promising collaterals for the retrograde approach, STAR successfully recanalized side branch 1. As main vessel failed to be recanalized, we proceeded with an AnteOwl IVUS-guided TDADR, intending guidewire penetration into the true lumen from the middle of the dissection plane at the main vessel, proximal to side branch 2 origin. Accurate wiring was achieved, and a guidewire was placed on side branch 2 for protection. After stent placement in the main vessel and kissing inflation, cutting balloon dilatation was performed to create re-entries for the STAR-induced extended main vessel haematoma. The procedure resulted in complete revascularization of main vessel and side branches. At 12-month follow-up, no further angina was reported, and coronary computed tomography showed patent side branches with no significant in-stent restenosis.
Imaging-based TDADR method was effective in our present case despite failed STAR technique. Limited IVUS and operator availability may become a barrier in implementing TDADR.
随着血管内超声（IVUS）引导下的尖端检测-正向夹层再入路（TDADR）技术的发现，治疗困难的慢性完全闭塞（CTO）病变的技术不断发展。本病例展示了TDADR作为内膜下跟踪和再入路（STAR）技术失败后的一种可行的补救方法。
一名78岁男性，接受最佳药物治疗后仍有稳定型心绞痛，因左旋支冠状动脉（LCX）残留CTO病变出现劳力性心绞痛。对LCX中段CTO进行经皮冠状动脉介入治疗，近端残端钝圆，夹层平面沿主血管和分支2扩展。由于逆行入路缺乏有前景的侧支循环，STAR成功再通分支1。由于主血管未能再通，我们采用AnteOwl IVUS引导的TDADR，试图将导丝从主血管夹层平面中部、分支2起始部近端穿透至真腔。成功实现准确布线，并在分支2放置导丝进行保护。在主血管置入支架并进行对吻扩张后，进行切割球囊扩张，为STAR导致的主血管血肿扩大处创建再入路。该手术使主血管和分支完全再血管化。在12个月的随访中，未报告进一步的心绞痛，冠状动脉计算机断层扫描显示分支通畅，支架内无明显再狭窄。
尽管STAR技术失败，但基于成像的TDADR方法在本病例中是有效的。IVUS设备有限和操作人员不足可能成为实施TDADR的障碍。
