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Percutaneous revascularization of chronic coronary occlusions: an overview
J A Puma1, M H Sketch, J E Tcheng
1Department of Medicine, Duke University Medical Center, Durham, North Carolina 27710, USA.
Insights
Percutaneous coronary intervention for chronic total occlusions can improve angina and left ventricular function in about 65% of patients. However, long-term success is limited by restenosis, with new devices offering limited current benefit.
Area of Science:
- Cardiology
- Interventional Cardiology
- Vascular Medicine
Background:
- Chronic coronary occlusions pose challenges in treatment due to poor percutaneous revascularization success and restenosis.
- The role of angioplasty in this patient group remains controversial.
- Existing reports may underestimate the prevalence of this condition.
Purpose of the Study:
- To evaluate the available information on angioplasty for chronic coronary occlusions.
- To assess the efficacy and predictors of success for percutaneous recanalization.
- To review procedural outcomes and long-term results.
Main Methods:
- Systematic review and analysis of published data on angioplasty for chronic total coronary occlusions.
- Identification of factors predicting procedural success and complications.
- Evaluation of outcomes such as symptom improvement, left ventricular function, and need for bypass surgery.
Main Results:
- Successful recanalization is achieved in approximately 65% of attempted procedures.
- Procedural success is predicted by occlusion age, absence of antegrade flow, occlusion morphology, collateral vessels, and lesion length.
- Anginal status improves in 70% of successful procedures, with infrequent need for subsequent bypass surgery.
Conclusions:
- Angioplasty for chronic total occlusions can improve symptoms and cardiac function in a significant portion of patients.
- Procedural success is influenced by specific lesion characteristics.
- Long-term success is limited by high rates of restenosis, and current new devices have shown disappointing results.
Abstract:
Patients with a chronic coronary occlusion often undergo coronary angiography after weeks to months of occlusion. The published reports underestimate the extent of this problem because such patients are often arbitrarily assigned to receive medical therapy or undergo bypass surgery as a result of poor success with percutaneous revascularization and substantial restenosis. Thus, there is controversy about the role of angioplasty in this patient cohort. The goal of this overview was to evaluate the available information about angioplasty in chronic coronary occlusions. The primary indication for attempted recanalization of a chronic coronary occlusion has been symptomatic angina pectoris. Anginal status often improves after successful procedures (70% vs. 31% with a failed procedure); left ventricular function may improve; and subsequent referral for coronary artery bypass graft surgery is uncommon (3% vs. 28% in unsuccessful cases). Successful recanalization is achieved in approximately 65% of attempted procedures. Inability to cross the stenosis with a guide wire is the most common cause of procedural failure. Statistically significant predictors of procedural success include older occlusions (75% < 3 months old vs. 37% > or = 3 months old), absence of any anterograde flow through the occlusion (76% with vs. 58% without), angiographically abrupt-appearing occlusions (50% vs. 77% with tapered occlusions), presence of bridging collateral vessels (23% with vs. 71% without) and lesions > 15 mm. Procedural complications occur at a slightly lower incidence than in angioplasty of high grade subtotal stenoses. Long-term success is limited, and restenosis can be expected in > 50% of the patients. The experience with chronic total occlusions of saphenous vein bypass grafts is small, but there appear to be limited procedural success and significant procedural complications, particularly associated with distal emboli. The role of new pharmacologic agents has yet to be defined and that of new devices has been disappointing so far, but further technologic advances are on the horizon.