采用心外膜侧支逆向法经皮冠状动脉介入治疗的慢性完全闭塞左前降支—英文课件.pptVIP

Percutaneous coronary intervention of a left anterior descending chronic total occlusion using an epicardial collateral retrograde approach Dr Patricia HT Hon Dr David CK Hu CTO-LAD retrograde approach 59 yo male exertional angina March ’07 Risk factors: hypertension, hyperlipidaemia, new onset Type 2 DM and smoking occasionally CTO-LAD retrograde approach CTA coronary angiogram: severe and extensive disease shown in RCA and LAD LV function satisfactory on echocardiogram CTO-LAD retrograde approach Diagnostic coronary angiogram March ’07: CTO mid LAD, severe proximal disease, good collateral retrograde filling from RCA Severe disease distal LCX, sub-total occlusion (TIMI-2)? 90% lesion mid RCA and 50% disease PDA CTO-LAD retrograde approach Management plan: PCI to RCA + surgical stand-by (high risk)? Staged revascularisation to CTO-LAD and LCX either surgically or by PCI CTO-LAD retrograde approach March’07: mid RCA stented successfully (Xience V 3.5mm x 23mm)? CTO-LAD retrograde approach Exercise nuclear perfusion scan 3 weeks after stenting of mid RCA: No significant ischaemia in LAD territory. Frequent PACs noted during exercise Option of revascularization of LCX and CTO-LAD or conservative therapy: patient chose latter CTO-LAD retrograde approach Enjoyed long periods of exercising vigorously without anginal symptoms Nov ’07: recurrence of chest discomfort and developed paroxysmal AF New ST depression on exercise treadmill CTO-LAD retrograde approach Restudy coronary angiogram Nov ’07: Patent RCA stent New lesion 80% proximal RCA LAD and LCX disease as before CTO-LAD retrograde approach Adhoc stenting to new lesion proximal RCA (Endeavor 3.5mm x 18mm)? Sub-total occlusion LCX stented (Endeavor 2.25mm x 14mm)? Attempted but failed to re-open CTO-LAD in antegrade approach CTO-LAD retrograde approach Options: PCI to CTO-LAD using retrograde approach vs CABG using LIMA to LAD (dual anti-platelet therapy)? CTO-LAD retrograde approach