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Original article
RESUMEN
Palabras clave: Introduccion y objetivos: La revascularizacion percutanea de las oclusiones cronicas totales supone un
Oclusion coronaria cronica desafo tecnico, y tiene una tasa de exito menor que las demas angioplastias. Conocer los predictores de
Tomografa computarizada fracaso permitira mejorar la seleccion de pacientes con mayores posibilidades de exito. Disenamos un
con multidetectores
estudio para identicar los datos de la tomografa computarizada con multidetectores que podran
Predictor de fracaso
asociarse a fracaso del tratamiento percutaneo de las oclusiones cronicas totales.
Metodos: Estudio prospectivo monocentrico sobre 69 pacientes consecutivos, portadores de una
oclusion cronica total, a los que se realizo una tomografa computarizada con multidetectores previa a la
revascularizacion.
Resultados: Se analizaron 77 lesiones, con una longitud ocluida media de 19,9 14,3 mm y una duracion
de la oclusion de 47 62 meses. El unico factor predictor angiograco independiente de fracaso de la
revascularizacion fue la presencia de una fuerte curva entre la placa y el vaso proximal permeable (odds
ratio = 3,8; intervalo de conanza del 95%, 1,2-12; p = 0,02). El unico factor derivado de la tomografa
computarizada con multidetectores asociado signicativamente con fracaso fue la presencia de un arco de
calcio que afectase a mas del 50% de la circunferencia del segmento ocluido en la porcion proximal (p = 0,04)
y media (p = 0,03).
Conclusiones: La tomografa computarizada con multidetectores identica una variable no cuanticable
por angiografa como predictora de fracaso de la revascularizacion de las oclusiones cronicas totales. En
casos seleccionados podra ser util para el cribado antes de la revascularizacion.
2011 Sociedad Espanola de Cardiologa. Publicado por Elsevier Espana, S.L. Todos los derechos reservados.
* Corresponding author: Secretara de Cardiologa, Hospital Clnic, Villarroel 170, escalera 3, 6.a planta, 08036 Barcelona, Spain.
E-mail address: 27700vmy@comb.cat (V. Martn-Yuste).
1885-5857/$ see front matter 2011 Sociedad Espanola de Cardiologa. Published by Elsevier Espana, S.L. All rights reserved.
doi:10.1016/j.rec.2011.11.008
Document downloaded from http://www.revespcardiol.org, day 12/08/2017. This copy is for personal use. Any transmission of this document by any media or format is strictly prohibited.
Table 1
Exclusion Criteria
Abbreviations
Woman of childbearing age or pregnant
CTO: chronic total coronary occlusion Participation in another clinical research protocol
HU: Hounseld units Allergy to iodinated contrast material, aspirin, or clopidogrel
MDCT: multidetector computed tomography Severe systemic disease or life expectancy less than 1 year
High risk for hemorrhage/high bleeding risk:
Bleeding diathesis
Gastrointestinal disease involving bleeding or a risk of bleeding, recently
INTRODUCTION diagnosed, of unknown cause, or untreated
Genitourinary tract disease
Chronic total coronary occlusion (CTO) is dened as a complete
Respiratory tract disease: hemoptysis in study, pulmonary neoplasm
interruption of coronary artery ow lasting more than 3 months. pending treatment
The duration of the occlusion is established by evidence on a
Impossible to follow prolonged dual antiplatelet therapy
previous coronary angiography study, a history of myocardial
Platelet decit or renal failure (creatinine >2 or clearance <30 mL/min)
infarction in territory corresponding to the occluded vessel, or a
change in the anginal pattern. In all other cases, the duration is Lack of adequate vascular access
METHODS
Figure 2. Quantifying calcium in the proximal, middle, and distal thirds. A: chronic total coronary occlusion with mild calcication, proximal (99 HU), middle
(156 HU), and distal (127 HU). B: chronic total coronary occlusion with severe calcication, proximal (247 HU), middle (409 HU), and distal (212 HU). HU,
Hounseld units.
Table 3
Angiographic Characteristics and Predictors of Successful Revascularization
Total (77 lesions) Guide wire success (n=53) Guide wire failure (n=24) p
Figure 3. Occluded coronary arteries with previously implanted stent. A: right coronary, middle and distal stent; high-density image (black arrows), occlusion of the
artery immediately proximal to the rst stent (white arrow). B: total chronic coronary occlusion difcult to evaluate because of an intense proximal calcication
(yellow arrow) of the vessel, middle occlusion, and distal stent (white arrow).
Calcium density was greater in the proximal third of the Revascularization Outcome
occlusion (219 HU, SD 195) than in the distal third (152 HU, SD
102). In addition, more extensive calcium inltration was seen in There was a mean of 1.3 revascularization attempts per patient
the proximal than in the distal third (calcium occupation 50%-75% (SD 0.7, range 1-4), mean duration of the procedure was 73 min
of the lumen arc in 30% vs 16% of vessels, respectively). The MDCT (SD 64), uoroscopy time was 42 min (SD 19), and 302 mL (SD 151)
characteristics of the CTOs studied are shown in Table 4. of contrast was used.
Table 4
Multidetector Computed Tomography Characteristics of Total Coronary Occlusions and Predictors of Revascularization Failure
Valid patients Total (n=73) Guide wire success (n=51) Guide wire failure (n=22) P
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ACKNOWLEDGMENTS
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grant from Toshiba to work in the acquisition and analysis of the
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computed tomography data. 64-multislice computed tomography in consecutive patients with suspected
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