Skip to main content
SpringerLink
Log in

Chronischer Koronarverschluss: Neue Techniken und Strategien

Chronic total coronary occlusion: New techniques and treatment strategies

  • Published:
Clinical Research in Cardiology Supplements Aims and scope

Zusammenfassung

In dieser Übersicht werden die gegenwärtigen und künftigen Strategien in der Behandlung eines chronischen Koronarverschlusses (CTO) vorgestellt und diskutiert. Die anerkannte Indikation für die Revaskularisation sind das Vorhandensein typischer Beschwerden, der Nachweis von viablem Myokard bei Patienten mit einem vorausgegangenen Myokardinfarkt und prognostische Überlegungen vor allem bei Patienten mit Mehrgefäßerkrankungen. Die überwiegende Mehrheit der Patienten mit CTO erfüllen diese Kriterien, werden aber gegenwärtig dennoch nicht in der erwarteten Häufigkeit interventionell behandelt.

In diesem Beitrag werden die Grundregeln für die Anwendung der neuen Drahttechniken zur interventionellen Revaskularisation und Weiterentwicklungen vorgestellt. Diese sollten breitere Anwendung finden, um eine höhere Interventionserfolgsrate auch in weniger erfahrenen Zentren zu erzielen, während die weiter fortentwickelten Ansätze einschließlich der retrograden Rekanalisationstechnik wenigen spezialisierten Institutionen vorbehalten sein sollten. Trotz dieser aggressiveren Ansätze zur Passage eines verschlossenen Gefäßes ist die Komplikationsrate nicht höher als bei nichtokklusiven Läsionen, wenn die spezifischen Komplikationen der Rekanalisation durch sorgfältige Vorgehensweise vermieden werden.

Abstract

This paper presents an overview of the current and future strategies for the treatment approach of chronic total coronary occlusions (CTOs). The established indications for revascularization are the presence of symptoms, detection of viable myocardium in patients with a previous acute myocardial infarction, and prognostic considerations especially in patients with multi-vessel disease. The vast majority of patients with a CTO fulfill these criteria but still seem to be considerably undertreated in current PCI practice.

The basic rules of applying the new wire techniques and the advancements are presented, which should be adopted more widely and would lead to an improvement of the procedural success rate also in nonspecialized centers, whereas the most advanced approaches such as the retrograde wiring and lesion recanalization may remain reserved for dedicated centers. Despite more aggressive approaches, the complication rate can be limited to that of nonocclusive lesions. However, awareness of the specific causes of complications in CTOs is warranted.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Literatur

  1. Abbott JD, Kip KE, Vlachos HA, Sawhney N, Srinivas VS, Jacobs AK, Holmes DR, Williams DO (2006) Recent trends in the percutaneous treatment of chronic total coronary occlusions. Am J Cardiol 97:1691–1696

    Article  PubMed  Google Scholar 

  2. Agostoni P, Valgimigli M, Biondi-Zoccai GG, Abbate A, Garcia HM, Anselmi M, Turri M, McFadden EP, Vassanelli C, Serruys PW, Colombo A (2006) Clinical effectiveness of baremetal stenting compared with balloon angioplasty in total coronary occlusions: insights from a systematic overview of randomized trials in light of the drug-eluting stent era. Am Heart J 151:682–689

    Article  PubMed  CAS  Google Scholar 

  3. Baks T, van Geuns RJ, Duncker DJ, Cademartiri F, Mollet NR, Krestin GP, Serruys PW, de Feyter PJ (2006) Prediction of left ventricular function after drug-eluting stent implantation for chronic total coronary occlusions. J Am Coll Cardiol 47:721–725

    Article  PubMed  CAS  Google Scholar 

  4. Christofferson RD, Lehmann KG, Martin GV, Every N, Caldwell JH, Kapadia SR (2005) Effect of chronic total coronary occlusion on treatment strategy. Am J Cardiol 95:1088–1091

    Article  PubMed  Google Scholar 

  5. Delacretaz E, Meier B (1997) Therapeutic strategy with total coronary artery occlusions. Am J Cardiol 79:185–187

    Article  PubMed  CAS  Google Scholar 

  6. Di Mario C, Werner GS, Sianos G, Galassi AR, Büttner J, Dudek D, Chevalier B, Lefevre T, Schofer J, Koolen JJ, Sievert H, Reimers B, Fajadet J, Colombo A, Gershlick AH, Serruys PW, Reifart N (2007) European perspective in the recanalisation of Chronic Total Occlusions (CTO): consensus document from the EuroCTO Club. EuroIntervention 3:30–43

    PubMed  Google Scholar 

  7. Gunning MG, Williams IL, Jewitt DE, Shah AM, Wainwright RJ, Thomas MR (2002) Coronary artery perforation during percutaneous intervention: incidence and outcome. Heart 88:495–498

    Article  PubMed  CAS  Google Scholar 

  8. Hannan EL, Racz M, Holmes DR, King SB III, Walford G, Ambrose JA, Sharma S, Katz S, Clark LT, Jones RH (2006) Impact of completeness of percutaneous coronary intervention revascularization on long-term outcomes in the stent era. Circulation 113:2406–2412

    Article  PubMed  Google Scholar 

  9. Heyne JP, Goernig M, Feger J, Kurrat C, Werner GS, Figulla HR, Kaiser WA (2007) Impact on adenosine stress cardiac magnetic resonance for recanalisation and follow up of chronic total coronary occlusions. Eur J Radiol 63:384–390

    Article  PubMed  CAS  Google Scholar 

  10. Hochman JS, Lamas GA, Buller CE, Dzavik V, Reynolds HR, Abramsky SJ, Forman S, Ruzyllo W, Maggioni AP, White H, Sadowski Z, Carvalho AC, Rankin JM, Renkin JP, Steg PG, Mascette AM, Sopko G, Pfisterer ME, Leor J, Fridrich V, Mark DB, Knatterud GL (2006) Coronary intervention for persistent occlusion after myocardial infarction. N Engl J Med 355:2395–2407

    Article  PubMed  CAS  Google Scholar 

  11. Hoye A, van Domburg RT, Sonnenschein K, Serruys PW (2005) Percutaneous coronary intervention for chronic total occlusions: the Thoraxcenter experience 1992–2002. Eur Heart J 26:2630–2636

    Article  PubMed  Google Scholar 

  12. Ito S, Suzuki T, Ito T, Katoh O, Ojio S, Sato H, Ehara M, Kawase Y, Myoishi M, Kurokawa R, Ishihara Y, Suzuki Y, Sato K, Toyama J, Fukutomi T, Itoh M (2004) Novel technique using intravascular ultrasound-guided guidewire cross in coronary intervention for uncrossable chronic total occlusions. Circ J 68:1088–1092

    Article  PubMed  Google Scholar 

  13. Kinoshita I, Katoh O, Nariyama J, Otsuji S, Tateyama H, Kobayashi T, Shibata N, Ishihara T, Ohsawa N (1995) Coronary angioplasty of chronic total occlusions with bridging collateral vessels: immediate and follow-up outcome from a large single-center experience. J Am Coll Cardiol 26:409–415

    Article  PubMed  CAS  Google Scholar 

  14. Loli A, Liu R, Pershad A (2006) Immediate-and short-term outcome following recanalization of long chronic total occlusions (>50 mm) of native coronary arteries with the Frontrunner catheter. J Invasive Cardiol 18:283–285

    PubMed  Google Scholar 

  15. Melzi G, Cosgrave J, Biondi-Zoccai GL, Airoldi F, Michev I, Chieffo A, Sangiorgi GM, Montorfano M, Carlino M, Colombo A (2006) A novel approach to chronic total occlusions: The crosser system. Catheter Cardiovasc Interv 68:29–35

    Article  PubMed  Google Scholar 

  16. Ochiai M, Ashida K, Araki H, Ogata N, Okabayashi H, Obara C (2005) The latest wire technique for chronic total occlusion. Ital Heart J 6:489–493

    PubMed  Google Scholar 

  17. Orlic D, Stankovic G, Sangiorgi G, Airoldi F, Chieffo A, Michev I, Montorfano M, Carlino M, Corvaja N, Finci L, Colombo A (2005) Preliminary experience with the Frontrunner coronary catheter: novel device dedicated to mechanical revascularization of chronic total occlusions. Catheter Cardiovasc Interv 64:146–152

    Article  PubMed  Google Scholar 

  18. Prasad A, Rihal CS, Lennon RJ, Wiste HJ, Singh M, Holmes DR Jr (2007) Trends in outcomes after percutaneous coronary intervention for chronic total occlusions: a 25-year experience from the Mayo Clinic. J Am Coll Cardiol 49:1611–1618

    Article  PubMed  Google Scholar 

  19. Saito S, Tanaka S, Hiroe Y, Miyashita Y, Takahashi S, Satake S, Tanaka K (2003) Angioplasty for chronic total occlusion by using tapered-tip guide-wires. Catheter Cardiovasc Interv 59:305–311

    Article  PubMed  Google Scholar 

  20. Silber S, Albertsson P, Aviles FF, Camici PG, Colombo A, Hamm C, Jorgensen E, Marco J, Nordrehaug JE, Ruzyllo W, Urban P, Stone GW, Wijns W (2005) Guidelines for percutaneous coronary interventions. The Task Force for Percutaneous Coronary Interventions of the European Society of Cardiology. Eur Heart J 26:804–847

    Article  PubMed  Google Scholar 

  21. Silber S, Borggrefe M, Böhm M, Hoffmeister HM, Dietz R, Ertl G, Heusch G (2007) Positionspapier der DGK zur Wirksamkeit und Sicherheit von Medikamente freisetzenden Koronarstents (DES). Der Kardiologe 1:84–111

    Article  Google Scholar 

  22. Smith SC Jr, Feldman TE, Hirshfeld JW Jr, Jacobs AK, Kern MJ, King SB III, Morrison DA, O’Neill WW, Schaff HV, Whitlow PL, Williams DO, Antman EM, Adams CD, Anderson JL, Faxon DP, Fuster V, Halperin JL, Hiratzka LF, Hunt SA, Nishimura R, Ornato JP, Page RL, Riegel B (2006) ACC/AHA/SCAI 2005 Guideline Update for Percutaneous Coronary Intervention – summary article: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (ACC/AHA/SCAI Writing Committee to Update the 2001 Guidelines for Percutaneous Coronary Intervention). Circulation 113:156–175

    Article  PubMed  Google Scholar 

  23. Stone GW, Colombo A, Teirstein PS, Moses JW, Leon MB, Reifart NJ, Mintz GS, Hoye A, Cox DA, Baim DS, Strauss BH, Selmon M, Moussa I, Suzuki T, Tamai H, Katoh O, Mitsudo K, Grube E, Cannon LA, Kandzari DE, Reisman M, Schwartz RS, Bailey S, Dangas G, Mehran R, Abizaid A, Serruys PW (2005) Percutaneous recanalization of chronically occluded coronary arteries: procedural techniques, devices, and results. Catheter Cardiovasc Interv 66:217–236

    Article  PubMed  Google Scholar 

  24. Stone GW, Rutherford BD, McConahay DR, Johnson WL Jr, Giorgi LV, Ligon RW, Hartzler GO (1990) Procedural outcome of angioplasty for total coronary artery occlusion: an analysis of 971 lesions in 905 patients. J Am Coll Cardiol 15:849–856

    Article  PubMed  CAS  Google Scholar 

  25. Suero JA, Marso SP, Jones PG, Laster SB, Huber KC, Giorgi LV, Johnson WL, Rutherford BD (2001) Procedural outcomes and long-term survival among patients undergoing percutaneous coronary intervention of a chronic total occlusion in native coronary arteries: a 20-year experience. J Am Coll Cardiol 38:409–414

    Article  PubMed  CAS  Google Scholar 

  26. Surmely JF, Katoh O, Tsuchikane E, Nasu K, Suzuki T (2007) Coronary septal collaterals as an access for the retrograde approach in the percutaneous treatment of coronary chronic total occlusions. Catheter Cardiovasc Interv 69:826–832

    Article  PubMed  Google Scholar 

  27. Surmely JF, Suzuki T (2006) Intravascular ultrasound-guided recanalization of a coronary chronic total occlusion located in a stent implanted subintimally: a case report. J Cardiol 48:95–100

    PubMed  Google Scholar 

  28. Surmely JF, Tsuchikane E, Katoh O, Nishida Y, Nakayama M, Nakamura S, Oida A, Hattori E, Suzuki T (2006) New concept for CTO recanalization using controlled antegrade and retrograde subintimal tracking: the CART technique. J Invasive Cardiol 18:334–338

    PubMed  Google Scholar 

  29. Van der Schaaf RJ, Vis MM, Sjauw KD, Koch KT, Baan J Jr, Tijssen JG, de Winter RJ, Piek JJ, Henriques JP (2006) Impact of Multivessel Coronary Disease on Long-Term Mortality in Patients With ST-Elevation Myocardial Infarction Is Due to the Presence of a Chronic Total Occlusion. Am J Cardiol 98:1165–1169

    Article  PubMed  Google Scholar 

  30. Werner GS, Bahrmann P, Mutschke O, Emig U, Betge S, Ferrari M, Figulla HR (2003) Determinants of target vessel failure in chronic total coronary occlusions after stent implantation. The influence of collateral function and coronary hemodynamics. J Am Coll Cardiol 42:219–225

    Article  PubMed  Google Scholar 

  31. Werner GS, Diedrich J, Scholz KH, Knies A, Kreuzer H (1997) Vessel reconstruction in total coronary occlusions with a long subintimal wire pathway: use of multiple stents under guidance of intravascular ultrasound. Cathet Cardiovasc Diagn 40:46–51

    Article  PubMed  CAS  Google Scholar 

  32. Werner GS, Ferrari M, Heinke S, Küthe F, Surber R, Richartz BM, Figulla HR (2003) Angiographic assessment of collateral connections in comparison with invasively determined collateral function in chronic coronary occlusions. Circulation 107:1972–1977

    Article  PubMed  Google Scholar 

  33. Werner GS, Fritzenwanger M, Prochnau D, Schwarz G, Krack A, Ferrari M, Figulla HR (2007) Improvement of the primary success rate of recanalization of chronic total coronary occlusions with the Safe-Cross system after failed conventional wire attempts. Clin Res Cardiol 96:489–496

    Article  PubMed  Google Scholar 

  34. Werner GS, Surber R, Küthe F, Emig U, Schwarz G, Bahrmann P, Figulla HR (2005) Collaterals and the recovery of left ventricular function after recanalization of a chronic total coronary occlusion. Am Heart J 149:129–137

    Article  PubMed  Google Scholar 

  35. Yamashita T, Kasaoka S, Son R, Gordon IL, Khan R, Neet J, Hedrick AD, Tobis JM (2001) Optical coherent reflectometry: a new technique to guide invasive procedures. Catheter Cardiovasc Interv 54:257–263

    Article  PubMed  CAS  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Medizinische Klinik I, Kardiologie & Intensivmedzin, Klinikum Darmstadt, Grafenstraße 9, 64283, Darmstadt, Germany

    G. S. Werner FESC, FACC

Authors
  1. G. S. Werner FESC, FACC
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to G. S. Werner FESC, FACC.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Werner, G.S. Chronischer Koronarverschluss: Neue Techniken und Strategien. Clin Res Cardiol Suppl 3, 78–84 (2008). https://doi.org/10.1007/s11789-008-0049-5

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11789-008-0049-5

Schlüsselwörter

Key words

Search

Navigation