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ABSTRACT
OBJECTIVE
To evaluate the technical success of percutaneous
coronary intervention of chronic total occlusion.
STUDY DESIGN
Observational study.
SETTING
Cardiology Department, Punjab Institute of
Cardiology, Lahore.
DURATION OF STUDY
i! months after approval of synopsis.
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METHODS:
"# Patients fulfilling inclusion and e!clusion criteria
$ere included after ta%ing informed consent on a consent
form &'ppendi! I(. ' proforma &'ppendi! II( $as used for
data Collection included parameters of study.
The study $as conducted at Punjab Institute of Cardiology,
Lahore.
Duration of occlusion $as defined as the elapsed
time, in months, from the onset of symptoms ´
myocardial infarction or change of anginal pattern( or on
coronary angiography.
'll patients received a loading dose of )## mg of
clopidogrel and then "* mg+d for months in addition to
-*# mg+d aspirin. 'll the PCIs of CTOs $ere performed by
e!perienced cardiologist. Local anesthesia $as given at the
site of arterial puncture that $as radial or femoral. '
fluoroscopy time of )# minutes $as allocated to $ire the
lesion. If the angioplasty guide $ire failed to progress, or
complications occurred such as coronary dissection,
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perforation or hemodynamic instability the procedure $as
abandoned and declared unsuccessful. election of
angioplasty guide $ires and supporting balloons $as at the
discretion of PCI operators. Operators progressed from soft
to stiff $ires. alloon pre/dilatation $as mandated before
stent placement. tent assignment $as blinded to both the
physician and the patient. are metal and drug eluting
stents $ere used of available lengths 0/-0 mm lengths and
1.*, ).#, and ).* mm diameters. They $ere identical in
appearance. Post dilation $as done to optimi2e
angiographic deployment. During the procedure,
intravenous heparin boluses $ere administered.
The procedure $as concluded on achievement of the
primary end point or any of the econdary end points.
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RESULTS:
3ean age of patients $as *1."4., mean height $as
-5".11 5.6 cm and mean $eight $as "5.) %g.
Out of "# patients *" &0-.67( $ere male -) &-0.5( $ere
female. 8egarding coronary artery ris% factors 11 &)-.67(
$ere Diabetic, ) &**."7( hypertensive, )6&60.57(
smo%ers, -"&16.)7( $ith family history of ischemic heart
disease and -)&-)7( had previous history of ischemic
heart disease.
Diseased artery $as L'D in )1 &6*."7(, LC9 in &-1.7(
and 8C' in 1 &6-.67(.
8egarding lesion characteristics of CTO Distal vessels
visuali2ed in *5 &0#7(, 'ntegrade :lo$ $as found in
6*&56.)7( ,8etrograde :lo$ 1*&)*."7(, and
Calcification found in &-1.7(.
8egarding Procedural characteristics ;8
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and 9/) )#7 -5&11.7(
Predictors of successful PCI tump shape $as Tapering in
65&5*."7( and :lat in 16&)6.)7(.
Collaterals $ere found in )5&*-.67(, ridging collaterals
$ere in -)&-0.57(, ide branch collatrals $ere in
61&5#7(
Length of leison $as ?-#mm in 6&*."7(, -#/1#mm in
)#&61.7(, >1#mm in )5 &*-.67(.
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CONCLUSION
KEY WORDS
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INTRODUCTION
Percutaneous coronary intervention &PCI( of chronic total
occlusion &CTO( is one of the major challenges in
interventional cardiology.-The true prevalence of CTO in the
general population is un%no$n because a certain proportion of
patients $ith CTO are either asymptomatic or minimally
symptomatic and never undergoes Coronary angiogram.-
Chronic total coronary occlusion &CTO( is a common problem
seen in -#/)#7 of patients undergoing PCI.1 The currently
accepted indication for re/canali2ation of a chronic coronary
occlusion is ischemic symptoms or inducible ischemia related
to the occluded vessel. 5The re/canali2ation of a chronic total
coronary occlusion leads to relief of angina and to recovery of
left ventricular function $ith a favorable effect on survival ).
Primary success rate is relatively lo$, as re/canali2ation of CTO
is a comple! procedure due to inability to cross the occlusion
$ith the guide $ire. 3oreover, the overall procedure and
fluoroscopy time is longer and e@uipment use is higher than
PCI of non/occluded Aessels and $ith a high recurrence rate.6/
*
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Percutaneous transluminal coronary angioplasty &PTC'(
of chronic coronary occlusions can be performed $ith a
success rate of 00.B#.07, but $ith a higher rate of
restenosis than after angioplasty of non/occluded vessels."
This study is designed to evaluate the outcome of PCI
of CTO in terms of technical success.
:urthermore to identify factors leading to successful
PCI i.e. tapered stump, smaller missing segment.
The study $ill clarify our understanding of PCI to CTO
in terms of patient selection $ho $ill be benefited most
from intervention and in $hom intervention should not be
performed. uccessful PCI for CTO has been sho$n to
alleviate anginal symptoms, improve left ventricular
ejection fraction, decrease the need for coronary bypass
graft surgery, and prolong life.
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REVIEW OF LITERATURE
HISTORICAL BACKGROUND
Over the past t$o centuries, the Industrial and
Technological 8evolutions and their associated economic
and social transformations have resulted in dramatic shifts
in the diseases responsible for illness and death.
Cardiovascular disease &CAD( has emerged as the dominant
chronic disease in many parts of the $orld, and early in the
1-stcentury it is predicted to become the main cause of
disability and death $orld$ide.0
't the beginning of the 1-stcentury, CAD accounts for
nearly half of all deaths in the developed $orld and 1*
percent in the developing $orld. y 1#1#, it is predicted
that CAD $ill claim 1* million lives annually and that
coronary heart disease &CD( $ill surpass infectious disease
as the $orlds number one cause of death and disability./-#
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The global rise in CAD is the result of a dramatic shift
in the health status of individuals around the $orld during
the course of the 1#thcentury. E@ually important, there has
been an unprecedented transformation in the dominant
disease profile, or the distribution of diseases responsible
for the majority of cases of death and debility. efore,
-##, infectious diseases and malnutrition $ere the most
common causes of death. These have been gradually
supplanted in some &mostly developed( countries by chronic
diseases such as CAD and cancer. 's this trend spreads to
and continues in developing countries, CAD $ill dominate as
the major cause of death by 1#1#, accounting for at least
one in every three deaths.--
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Coronary angiogra!y
Coronary angiography remains the Fgold standardG for
identifying the presence or absence of arterial narro$ing
related to atherosclerotic coronary artery disease.-1 The
first selective coronary angiogram $as performed in -*0
by Dr. :. 3ason ones, ;r., a cardiologist at The Cleveland
Clinical :oundation.-) Huite accidentally, the catheter
positioned in the aorta for an angiogram to assess aortic
insufficiency dove into the 8C', and an image $as obtained
before it $as fully reali2ed $hat had occurred.
=hen Dr. ones and Dr. Earl hirey published their
results of more than -,### procedures in -51, interest in
coronary angiography surged. 8adiologists played an
important role in the development of catheteri2ation
techni@ues in the early -5#s. Je$ preformed catheter
designs, such as those by Dr. 3elvin ;ud%ins and Dr. urt
'mplat2, enabled selective angiography to be performed
$ith greater ease than $as previously possible $ith the
ones catheters. 'dditionally, percutaneous approaches
$ere also no$ possible, and arterial cut/do$ns $ere no
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longer re@uired. Improvements in radiographic imaging
concomitantly led to better image @uality.-)
"#r$%&an#o%' $oronary inr(#n&ion
Percutaneous coronary intervention &PCI(,
traditionally %no$n as percutaneous transluminal coronary
angioplasty &PTC'( or simply coronary angioplasty, has
emerged, predominantly as balloon angioplasty, in its first
1# years as the most common major medical intervention.
Coronary balloon angioplasty is an offspring of transluminal
angioplasty of peripheral arteries initiated by Dotter and
;ud%ins in -56.-6
Their method of dilating stenoses by successively
introducing a coa!ial double catheter $ith a diameter of 0:r
&1." mm( and -1 :r &)." mm(, respectively, $as crude. It
re@uired an access hole $ith a diameter e@ual to the target
lumen. In
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$here it $as used as an alternative to coronary artery
bypass grafting &C'
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elf e!panding $ire mesh stents $ere initially used
but never attained broad clinical use because of high
thrombosis rate. In contrast, a series of balloon e!pandable
stents has been available in Knited tates since -6.-
Initially bare metal stent &3( $ere used $hich are
e!pandable, balloon mounted, stainless steel, fle!ible,
laser/cut and polished, slotted tubes. Compared to PTC'
alone, stents reduce restenosis by appro!imately )# 7 in
patients of C'D.1-
'lthough stent implantation itself has been sho$n to
reduce restenosis but in/stent restenosis still occurs in -#/
6# 7 of the patients. ' large body of evidence has heen
accumulated to understand the processes involved in
restenosis. It $as evident that follo$ing mechanical
dilatation and stent implantation, neointimal formation,
$hich, $hen e!cessive, may re/narro$ the vessel lumen
&restenosis(. Ktili2ing the stent itself as the plateform for
local drug delivery is an appealing approach. The local
agent should be one that inhibits the comple! cascade of
events that leads to neointimal formation after stent
implantation.
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irolimus eluting stents are available for clinical use in
Europe, 'sia and outh 'merica since 1##1 and in Knited
tates since 1##). irolimus &8apamycin(, is a naturally
occurring macrocyclic lactone $ith a potent
immunosuppressive action used in renal transplantation
recipients since -, approved by Knited tates :ood and
Drug 'dministration &:D'(.
Polymer coated paclita!el eluting stents have been
commerciali2ed in Europe, 'sia and outh 'merica since
1##) and in Knited tates since 1##6. Paclita!el $as
originally isolated from the bar% of Pacific Me$, an
antiplatelet agent, currently used to treat breast and
ovarian cancer.
's e@uipment design and operator e!perience evolved
rapidly over the last t$o decade, PCI is e!panded to a
broader spectrum of patients, such as those $ith
multivessel disease, more challenging anatomy, reduced
left ventricular function, and other serious comorbid
medical conditions.-
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RISK FACTORS )or Coronary arry *i'#a'#
The global variation in CAD rates is related to
temporal and regional variations in %no$n ris% behaviors
and factors. Ecological analyses of major CAD ris% factors
and mortality demonstrate high correlations bet$een
e!pected and observed mortality rates for the three main
ris% factorsN smo%ing, serum cholesterol and hypertension
and suggest that many of the regional variations are based
on differences in conventional ris% factors.11/1)
- In$r#a'ing ag#: Over 0) percent of people $ho die of
coronary heart disease are of 5* years or older. 't
older ages, $omen $ho have heart attac%s are more
li%ely than men, are to die from them $ithin a fe$
$ee%s.
1 Ma+# '#, -g#n*#r.: 3en have a greater ris% of heart
attac% than $omen do, and they have attac%s earlier
in life. Even after menopause, $hen $omens death
rate from heart disease increases, its not as great as
mens.
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) H#r#*i&y in$+%*ing Ra$#: Children of parents $ith
heart disease are more li%ely to develop it
themselves. 3ost people $ith a strong family history
of heart disease have one or more other ris% factors.
;ust as one cant control age, se! and race, one cant
control family history. Therefore, its even more
important to treat and control any other ris% factor
one has.
6 To/a$$o '0o1#: mo%ers ris% of developing coronary
heart disease is 1B6 times that of nonsmo%ers.
Cigarette smo%ing is a po$erful independent ris%
factor for sudden cardiac death in patients $ith
coronary heart diseaseN smo%ers have about t$ice
the ris% of nonsmo%ers. Cigarette smo%ing also acts
$ith other ris% factors to greatly increase the ris% for
coronary heart disease. People $ho smo%e cigars or
pipes seem to have a higher ris% of death from
coronary heart disease &and possibly stro%e( but their
ris% isnt as great as cigarette smo%ers. E!posure to
other peoples smo%e increases the ris% of heart
disease even for nonsmo%ers.
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* Drin1ing a+$o!o+: It can indirectly contribute to
coronary artery disease. Drin%ing too much alcohol
can raise blood pressure, cause heart failure and lead
to stro%e. It can contribute to high triglycerides,
cancer and other diseases, and produce irregular
heartbeats. It contributes to obesity, alcoholism,
suicide and accidents.
5 Hig! /+oo* r#''%r#: igh blood pressure increases
the hearts $or%load, causing the heart to thic%en and
become stiffer. It also increases ris% of stro%e, heart
attac%, %idney failure and congestive heart failure.
=hen high blood pressure e!ists $ith obesity,
smo%ing, high blood cholesterol levels or diabetes,
the ris% of heart attac% or stro%e increases several
times.16/1*
" Hig! /+oo* $!o+#'ro+: 's blood cholesterol rises, so
does ris% of coronary heart disease. =hen other ris%
factors &such as high blood pressure and tobacco
smo%e( are present, this ris% increases even more. '
persons cholesterol level is also affected by age, se!,
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heredity and diet.15
0 "!y'i$a+ ina$&i(i&y: 'n inactive lifestyle is a ris% factor
for coronary heart disease. 8egular, moderate/to/
vigorous physical activity helps prevent heart and
blood vessel disease. The more vigorous the activity,
the greater are the benefits. o$ever, even
moderate/intensity activities help if done regularly
and long term. Physical activity can help control blood
cholesterol, diabetes and obesity, as $ell as help
lo$er blood pressure in some people.1"/10
O/#'i&y an* o(#r2#ig!&: People $ho have e!cess
body fat, especially if a lot of it is at the $aist, are
more li%ely to develop heart disease and stro%e even
if they have no other ris% factors. E!cess $eight
increases the hearts $or%. It also raises blood
pressure and blood cholesterol and triglyceride levels,
and lo$ers DL cholesterol levels. It can also ma%e
diabetes more li%ely to develop. 3any obese and
over$eight people may have difficulty losing $eight.
ut by losing even as fe$ as -# pounds, one can
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ANATOMY
ARTERIAL SU""LY OF THE HEART
The arterial supply of the heart is provided by the right and
left coronary arteries, $hich arise from the ascending aorta.
They supply the myocardium, including papillary muscles
and conducting tissue. The coronary arteries and its
branches are distributed over the surface of the heart, lying
$ithin the subepicardial connective tissue.)1
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Fig34: Coronary arri#' anrior (i#2
Source: www.houstonheartcenter.com/Coronary_Arteries
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RIGHT CORONARY ARTERY -RCA.
The right coronary artery arises from the anterior aortic
sinus of the ascending aorta and run for$ard bet$een the
pulmonary trun% and the right auricle. It descends almost
vertically in the right atrioventricular groove, and at the
inferior border of the heart it continues posteriorly along
the atrioventricular groove to anastomose $ith the left
coronary artery in the posterior interventricular groove. The
follo$ing branches of right coronary artery &8C'( supply
the right atrium, right ventricle and parts of left atrium, left
ventricle and the atrioventricular septum.))
BRANCHES OF RCA
Rig!& $on%' arrysupplies the anterior surface of
the pulmonary conus &infundibulum of the right ventricle(
and the upper part of the anterior $all of the right ventricle.
Anrior (#n&ri$%+ar /ran$!#'are t$o or three in
number, and supply the anterior surface of the right
ventricle.
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The 0argina+ /ran$!is the largest and runs along
the lo$er margin of the costal surface to reach the ape!.
The o'rior (#n&ri$%+ar /ran$!#'are usually t$o
in number and supply the diaphragmatic surface of the
right ventricle.
A&ria+ /ran$!#' supply the anterior and lateral
surface of the right atrium. One branch supplies the
posterior surface of the both the right and left atria.
The arry o) 'in%a&ria+ no*#supplies the node and
the right and left atriaN in )*7 of the individuals it arises
from the left coronary artery.)1
"o'rior inr(#n&ri$%+ar -*#'$#n*ing. arry
runs to$ard the ape! in the posterior interventricular
groove. It gives off branches to the right and left ventricle,
including its inferior $all. It supplies branches to the
posterior part of the ventricular septum but not to the
apical part, $hich receives its supply from the anterior
interventricular branch of the left coronary artery. ' large
septal branch supplies the atrioventricular node.In -#7 of
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individual the posterior interventricular artery is replaced by
a branch from the left coronary artery3
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Fig35: Coronary arri#' o'rior (i#2
Source: www.houstonheartcenter.com/Coronary_Arteries
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LEFT CORONARY ARTERY -LCA.
The left coronary artery is usually larger than the
right coronary artery, supplies the major part of the heart,
including the greater part of left atrium, left ventricle, and
ventricular septum. Left main stem &L3( or left main
coronary artery arises from the left posterior aortic sinus of
the ascending aorta and passes for$ard bet$een the
pulmonary trun% and left auricle.
Left main coronary artery then enters the
atrioventricular groove and divides into left anterior
descending &L'D( branch and left circumfle! branch &LC9(.
LAD:Left anterior descending branch runs do$n$ard in the
anterior interventricular groove to the ape! of the heart.
L'D gives rise to septal perforating branches to supply the
interventricular septum and diagonal branches that supply
antero/ lateral $all. It then bifurcates distally and tapers
out as a F$hales tailG at the cardiac ape!, although
sometimes it $raps around the ape! to supply part of the
inferior $all.
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LC6: Left circumfle! branch &LC9( courses along the left
atrioventricular groove and provides small atrial branches to
the left atrium and marginal branches that supply the
lateral $all of the left ventricle. The marginal branches are
sometimes referred to as lateral branches, $ith the first
marginal branch called the high lateral and subse@uent
lateral branches referred to as lateral or posterolateral
branches. Occasionally, L3 trifurcates to give rise also to a
ramus intermedius branch that supplies the high lateral $all
of left ventricle.)1
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"HYSIOLOGY OF THE CORONARY BLOOD
FLOW
Coronary flo$ is a function of driving pressure and
resistance, it can be stated in the e@uation HP+8 $here H
is coronary flo$, P is the driving pressure across the
coronary vascular bed and 8 is the total coronary
resistance. 8esistance can be in three forms, 8-Aiscous
resistance, 81'utoregulatory resistance and
8)Compressive resistance.
1) VISCOUS RESISTANCE -R4.Q
It is the impedance to flo$ offered by the entire coronary
vascular bed during diastole $hen fully dilated and can be
considered to be relatively static.
5. AUTOREGULATORY RESISTANCE -R5.:
It is four to five times greater than 8-, is the major
component of resistance and is thought to result from tonic
contraction of vascular smooth muscle at the arteriolar
level.**It has three mechanisms, metabolic, neurohumoral
and myogenic $hich adjust arteriolar tone.
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7. COM"RESSIVE RESISTANCE -R7.:
It arises from compression of vascular channels by
intramyocardial pressure as it varies through the cycle.
There is an intramyocardial systolic pressure gradient that
varies through the cycle. This intramyocardiac systolic
pressure gradient varies from 1#/6# mm g in the outer
third of myocardium to -## mm g in the inner third.
Diastolic intramyocardial pressures have been measured at
6/1# mm g $ithout a transmural gradient. In the empty
beating &on cardiopulmonary by pass( normal or
hypertrophic heart, the gradient in myocardial tissue
pressure persists. Aentricular fibrillation is associated $ith a
continuous gradient across the ventricular $all and a
subendocardial pressure of *#mm g in the normal heart
and 5"mm g in the hypertrophic heart.
The transmural gradient in intramyocardial pressure during
systole is primarily responsible for the normal phasic
coronary flo$ in $hich "#/0#7 of flo$ occurs during
diastole. Thus, little or no flo$ reaches the middle and deep
myocardium during systole $hen flo$ is limited to more
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superficial layers of the myocardium. In order to
compensate for this systolic maldistribution a
correspondingly greater proportion of diastolic flo$ must be
delivered to the inner myocardium. This is accomplished by
reduction of autoregulatory tone in the deeper myocardium
so that resistance is lo$er than in the more superficial
myocardium permitting greater subendocardial perfusion.)*
MYOCARIAL O6YGEN CONSUM"TION
eart provides blood for the circulatory needs of the bodyN
similarly it also supplies its o$n metabolic re@uirements
through the coronary circulation. ecause of limited
capacity for anaerobic metabolism to support cardiac $or%,
its metabolism can be considered essentially aerobic. '
uni@ue feature of the coronary circulation is the high degree
of o!ygen e!traction under basal conditions so that the
heart can adjust to changing o!ygen needs by only a small
increment in o!ygen e!traction. Increasing o!ygen
re@uirements must be met by proportionate increases in
coronary flo$.)5
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'nimal studies have delineated factors that govern o!ygen
re@uirements of the myocardium. 'lthough mean
myocardial o!ygen consumption &3AO1( is difficult to
measure, clinical studies have been consistent $ith
laboratory data. The normal heart has sufficient reserve to
meet myocardial o!ygen needs.
O!ygen consumption correlated $ith the tension time inde!
only until the pea% systolic pressure had been attained at
$hich -7 of o!ygen consumption per beat had occurred.)"
Thus myocardial o!ygen consumption is not a uniform
function of duration of systole &tension time inde!( because
it is insensitive to the duration of pressure maintenance
bet$een pea% systolic pressure and the end of rela!ation.
=all stress is more fundamentally related to 3AO1 then is
pressure development.)0
3yocardial contractility or inotropic state is the second
major determinant of 3AO1. Inotropic interventions
&norepinephrine, calcium or paired electrical stimulation(
that increase Ama! by *#7 result in a 6#7 increase in
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3AO1. 3yocardial contractility is as important as pressure
development as a determinant of 3AO1.)
The fairly direct relationship bet$een heart rate and
myocardial o!ygen consumption is $ell %no$n. =hen
o!ygen consumption per beat is measured, it did not
e!ceed that $hich could be accounted for on the basis of
the concomitant increase in the velocity of the contractile
element. asal o!ygen re@uirement of the potassium/plegic
heart is about 1#7 of the o!ygen consumption of the
$or%ing heart. The o!ygen cost of electrical activation of
the heart has been determined to be less than -7 of the
o!ygen need of the normal $or%ing heart.
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"ATHOLOGY
'lmost all myocardial infarctions result from coronary
atherosclerosis, generally $ith superimposed coronary
thrombosis. Prior to the fibrinolytic era, clinicians typically
divided patients $ith myocardiacl infarction into those
suffering a H/$ave and those suffering a non/H/$ave
infarct, based on the evolution of the pattern on the EC-.6.
2. istory of prior PCI.
3. istory of prior C'
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STATISTICAL ANALYSIS
Data $as analy2ed on P version -6.#. Jominal variables
$ere presented as the fre@uencies and percentages and
continuous variables $ere e!pressed as the mean 4
standard deviation. ince it $as an observational study so
no test of significance $ere applied.
ETHICAL ISSUES
'll patients or their legally authori2ed
representatives $ere e!plained about the study and $ritten
informed consent $as obtained.
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RESULTS
8esults $ere compiled after studying the specific variables.
"# patients $ere included in this study that fulfilled
inclusion criteria.
3ean age of patients $as *1."4., mean height$as-5".11 5.6 cm and mean $eight $as "5.) %g.
Out of "# patients *" &0-.67( $ere male -) &-0.5( $ere
female. 8egarding coronary artery ris% factors 11 &)-.67(
$ere Diabetic, ) &**."7( hypertensive, )6&60.57(
smo%ers, -"&16.)7( $ith family history of ischemic heart
disease and -)&-)7( had previous history of ischemic
heart disease.
Diseased artery $as L'D in )1 &6*."7(, LC9 in &-1.7(
and 8C' in 1 &6-.67(.
8egarding lesion characteristics of CTO Distal vessels
visuali2ed in *5 &0#7(, 'ntegrade :lo$ $as found in
6*&56.)7( ,8etrograde :lo$ 1*&)*."7(, and
Calcification found in &-1.7(.
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8egarding Procedural characteristics ;8 1#mm in )5 &*-.67(.
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TABLE 43 Ba'#+in# $!ara$ri'&i$'
Characteristics
Jumbers
&n"#(
&7(
'ge mean years *1."4.
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Aaraiables Jumbers &percentage(
eight mean &cm( -5".115.6
=eight mean &%g( "5.)
Diseased vessel
L'D
LC!
8C'
)1 &6*."7(
&-1.7(
1&6-.67(
Table ) 'ngiographic lesion chraterstics of CTO
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Aaraiables Jumbers &percentage(
Distal vessels visuali2ed *5 &0#7(
'ntegrade :lo$ 6*&56.)7(
8etrograde :lo$ 1*&)*."7(
Calcification &-1.7(
Table 6 Q Procedural characteristics
Characteristics Jumbers &7(
G%i*#r %'#*
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;8/6
9/)
1&6-.67(
6-&*0.57(
Wir# $ro''#* 2i&! /a++oon
'%or&
*6&""7(
TIMI III )+o2 a$!i#(#* *6&""7(
T#$!ni$a+ '%$$#'' *6&""7(
R#'i*%a+ 'no'i' -5&11.7(
Ta/+# ?: "r#*i$&or' o) '%$$#'')%+ "CI
Varia/+#' N%0/#r' ->.
S&%0 '!a#
Tapering
:lat
65&5*."7(
16&)6.)7(
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intervention and that the success rate in late chronic
occlusion $as significantly lo$er than that in early chronic
occlusion.
In our study, the factors affecting the success of transradial
PCI for CTO $ere also similar to these previous reports.
'lthough the success of a CTO intervention might
dependent on e!perience, the lesion type, and indications
for intervention, the devices used for the procedure are
critically important to the outcome, particularly in the case
of transradial intervention. =hen the radial approach for
CTO intervention is attempted, availability of sufficient
guiding support becomes a major concern since it is
generally not feasible to use a guiding catheter larger than
" :r. 'ccordingly, transfemoral coronary intervention is
often preferred over transradial PCI for CTO because " or 0
:r guiding catheters may be used to obtain greater bac%/up
support, as compared to the 5 :r guiding catheters
fre@uently used in the transradial approach. o$ever,
because catheter materials have improved a great deal, and
because special curvature is available to increase support,
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$e $ere able to achieve sufficient guiding support $ith a 5
:r guiding catheter in most cases.
In this study, the selection of guiding catheters $as based
on the lesion characteristics and the radial artery si2e. ' 5
:r guiding catheter $as most fre@uently used. The type of
guiding catheters used for CTO $as similar to those needed
for transradial PCI for other coronary lesions. In our study,
transradial PCI for a CTO lesion $as possible using 9 ).#
guiding catheters in *0.57 $hen the lesion $as in the left
coronary artery and in 6-.67 ;ud%ins right guiding catheter
$as used for lesions in the right coronary artery. The
;ud%ins right guiding catheter $as used less often,
compared $ith the results reported by Lotan et al"# $ho
reported that ;ud%ins &;L( guiding catheters $ere used in
67 of cases for the left coronary artery, $hile ;ud%ins &;8(
guiding catheters $ere used in *"7 of cases for the right
coronary artery in transradial PCI.
im et al0# evaluated the feasibility of the transradial
coronary intervention &T8CI( in 0* consecutive patients
$ith chronic total occlusion &CTO(. Clinical, angiographic
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and procedural factors $ere compared bet$een the success
and failure groups. 'n overall success rate of 5*.*7 &*" of
0" lesions( $as achieved $ith T8CI, and the most common
cause of failure $as an inability to pass the lesion $ith a
guide$ire. ' multivariate analysis demonstrated that the
most significant predictor of failure $as the duration of
occlusion. The procedural success rate improved $ith use of
ne$/generation hydrophilic guide$ires. The 5 :r guiding
catheters $ere used in the majority of the "# cases &0-7(.
:ive cases $ere crossed over to a femoral artery approach
due to engagement failure of the guiding catheter into the
coronary ostium because of severe subclavian tortuosity
and stenosis in t$o cases, radial artery looping in one case,
and poor guiding support in t$o cases. There $ere no
major entry site complications.0
Par% et al"- reported a total of -* patients had total
occlusion lesions &".67(. Percutaneous coronary
interventions $ere attempted in -)5 total occlusion lesions
&55.#7( in -)6 patients. uccessful recanali2ation $ith
stent implantation $as accomplished in 0 lesions, $ith a
procedural success rate of 55.67. One procedure/related
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death occurred because of no/reflo$ phenomenon. 'fter
e!cluding 0 patients $ith bundle branch bloc%, H and T
$ave inversions $ere observed in 5# &)1.-7( and "0
patients &6-."7(, respectively. The presence of H $aves
$as associated $ith severe angina, decreased left
ventricular ejection fraction, regional $all motion
abnormality, and T $ave inversion, but $as not related to
procedural success. Percutaneous coronary intervention is a
safe and useful procedure for the revasculari2ation of
coronary chronic total occlusion lesions. The procedural
success rate $as not related to the presence of pathologic
H $aves, $hich $ere associated $ith severe angina and
decreased left ventricular function."-
oye et el"1 reported a total of 0"6 consecutive patients
$ere treated for 00* CTO lesions. 3ean follo$/up time $as
6.6"R1.5 years. Patients $ere evaluated for the
occurrence of major adverse cardiac events &3'CE(
comprising death, acute myocardial infarction, and need for
repeat revasculari2ation $ith either coronary artery bypass
surgery or PCI. uccessful revasculari2ation $as achieved in
*"5 lesions &5*.-7(, in $hich stent implantation $as used
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in 0-.#7. 't )# days, the overall 3'CE rate $as
significantly lo$er in those patients $ith a successful
recanali2ation. 't * years, survival $as significantly higher
in those patients $ith a successful revasculari2ation. In
addition, there $as a significantly higher survival free of
3'CE, $ith the majority of events reflecting the need for
repeat intervention. Independent predictors for survival
$ere successful revasculari2ation, lo$er age, and the
absence of diabetes mellitus and multivessel disease. oye
et al") concluded that successful percutaneous
revasculari2ation of a CTO leads to a significantly improved
survival rate and a reduction in major adverse events at *
years. 3ost events relate to the need for repeat
reintervention, and the introduction of drug/eluting stents,
$ith lo$/restenosis rates, encourages the development of
technologies to improve recanali2ation success rates.
o$ever, failed recanali2ation may be associated acutely
$ith an adverse event, and ne$ technologies must focus on
a safe approach to successful recanali2ation.
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CONCLUSION
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"ROFORMA
TITLEQ
TECHNICAL SUCCESS OF "ERCUTANEOUS CORONARY
INTERVENTION OF CHRONIC TOTAL OCCLUSION
S.NO: Registration NO:
Name: Age:
Height: eight:
Se!: M / F A""ress:
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CONVENTIONAL CORONARY ANGIOGRAPHIC LESION
DESCRIPTION:
LAD:#ro!:Y / N $i":Y / N %ista&:Y / N 'esse& "iameter:
(esion &ength
LCx:#ro!:Y / N $i":Y / N %ista&:Y / N 'esse& "iameter:
(esion &ength
Intermediate:#ro!:Y / N $i":Y / N %ista&:Y / N 'esse& "iameter:
(esion &ength
RCA:#ro!:Y / N $i":Y / N %ista&:Y / N 'esse& "iameter:
(esion &ength
Si"e ranch &ocation within 2 mm o* &esion: Y / N
Stum+ sha+e: ,a+ering: Y / N -&at:Y / N
%uration o* C,O: Ca&ci*ication:Y / N
Co&&atera&s:Y / N ri"ging co&&atera&s:Y / N
C,O esse&: LAD/ RCA/ LCX/ Intermediate
%ista& esse& isua&i0e":Y / N
LESION LENGTH:
1 mm:Y / N 12 mm:Y / N 42 mm:Y / N
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FLO DYNAMICS ACROSS LESION:
Antegra"e *&ow:Y / N Retrogra"e *&ow:Y / N
5ui"er use":
PROCED!RE VARIA"LES:
5ui"e wire use" to cross the &esion: with or without a&&oon
su++ort:
a&&oon use": 6666666666666.
7n*&ations gien:
Sing&e:Y / N $u&ti+&e:Y / N
Stent ran": %e+&oyment +ressure:
-&ouro time: #roce"ure time:
,7$7 *&ow gra"e 3: 8 / N
Stenosis 39: 8 / N
,echnica& success: 8 / N
Pr#$ed%re &%$$e&&'%(: Y / N
Fai(%re #' )%ide *ire t# $r#&& t+e (e&i#n: Y / N
%issection: Y / N
#er*oration: Y / N
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C$ (ee& Raise": Y / N
Car"iac ,am+ona"e: Y / N
#eri+roce"ura& "eath: Y / N