Post Stenting Assessment Of Re Endothelialization With Optical Frequency Domain Imaging After Chronic Total Occlusion Procedure Design And Rationale Of The Perfe Cto Study Anglais
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Post-stEnting Assessment of Re-endothelialization with Optical Frequency Domain Imaging AftEr Chronic Total Occlusion Procedure Design and Rationale of the Perfe-CTO Study, Anglais
Introduction: Le traitement des occlusions coronaires totales chroniques (CTO) par angioplastie dans des centres expérimentés est un des grands progrès de la dernière décennie dans la prise en charge de la cardiopathie ischémique. Suivi par ses résultats préliminaires, les auteurs présentent dans ce travail le rationnel et la conception de l'étude prospective et multicentrique Perfe-CTO. Méthodes et résultats: Décrits comme des facteurs prédictifs de thrombose de stent et de survenue d'évènements cardiovasculaires, le recouvrement néo-intimal, la mal-apposition des mailles de stent et le pourcentage de prolifération néo-intimale seront systématiquement évalués par tomographie en cohérence optique fréquentielle (OFDI) intra-coronaire sur toute la longueur des stents actifs à libération de sirolimus avec polymère biodégradable immédiatement et 3 mois après leur implantation lors de la désobstruction d'une CTO. D'après l'analyse de 13 CTO soit un total de 18,765 mailles et 1864 segments millimétriques, la mal-apposition après stenting et à 3 mois concernait respectivement 5,5% et 5,7% des mailles. A 3 mois, 14,8% des mailles n'étaient pas couvertes avec un pourcentage moyen de proliferation néo-intimale par lésion de 3,78%. Le processus de recouvrement des mailles était significativement retardé au niveau des segments distaux des endoprothèses. Au total, le recours à l'OFDI a révélé une anomalie justifiant un traitement complémentaire dans 31% des cas alors que le résultat angiographique final était considéré optimal. Conclusion: Les résultats préliminaires de cette étude pilote associés à une revue de la littérature suggèrent que le remodelage histologique complexe des CTO pourrait affecter à court-terme la cicatrisation après angioplastie par une grande incidence de mal-apposition et une hétérogénéité spatiale du processus de recouvrement néo-intimal.
Chronic Total Occlusions
Understand and remedy chronic total occlusions with the third edition of this comprehensive guide Chronic Total Occlusions offers the most comprehensive overview of chronic total occlusions (CTO) on the market, authored by two internationally recognized physician educators. It covers both the diagnostic modalities and treatment methods required to tailor a treatment program to individual cardiological patients with the greatest possible chance of success. Thorough and informed by the latest research and field data, the third edition of this guide is an indispensable resource for interventional cardiologists. In Chronic Total Occlusions: A Guide to Recanalization, Third Edition, readers will also find: Full-color images to guide diagnosis of CTOs Expert tips and tricks for key procedures involved in treating challenging cases Clinical case studies illustrating specific scenarios and frequently encountered complications Chronic Total Occlusions: A Guide to Recanalization, Third Edition is a must-have for interventional cardiologists who want to maximize their patient outcomes.
Novel Uses for Ultrasound as Both an Imaging and Therapeutic Tool in the Characterization and Percutaneous Revascularization of Chronic Total Occlusion
Revascularization of Chronic Total Occlusions (CTO) by percutaneous coronary interventions is limited by low success rates, primarily due to difficulty in guidewire crossing. There are a number of contributing factors that make guidewire crossing challenging. Two of the most significant impediments are: a) inability to adequately visualize the CTO to appropriately plan a pathway to the distal lumen, and b) difficulty in physically crossing the rigid endcap at the proximal end of CTO without using stiff wires. Moreover, there is a significant knowledge gap in the composition of CTOs, and the consequent impact of that composition on crossability.Recent studies have suggested that the presence of microvessels in CTO may provide a preferred pathway for guidewire crossing. However, due to limited resolution and a lack of soft tissue contrast in angiography, microvessels within CTO cannot generally be detected by in-vivo angiographic techniques, and when they are visualized, it is unknown whether or not they are intraluminal. In this thesis, high frequency ultrasound with Power Doppler overlays is shown to be capable of detecting and tracking transluminal recanalization channels using an in vivo porcine model of CTO. It is also shown that ultrasound is a more sensitive technique to detect and map these channels than MRI. Furthermore, features of microvasculature in CTOs that had not previously been seen are presented.A technique was then developed to facilitate guidewire crossing through the proximal endcap, also known as the proximal fibrous cap (PFC). In order to assess the ease with which a probe is able to perforate the PFC, a system was designed and to measure the force required for PFC puncture. This system was validated by examining the required puncture forces for CTOs of different ages. It was shown that CTOs less than 6 weeks in age are significantly easier to puncture than those greater than 12 weeks. This coincides with differences in composition, with the presence of softer materials at the earlier time point, such as thrombus and proteoglycans compared to stiffer fibrotic materials which predominate at late timepoints.This thesis presents tools and techniques to help mitigate the current shortcomings, while shedding new light on CTO composition and maturation. The tools and techniques presented herein are based upon ultrasound approaches with the intent of eventually developing these strategies into catheter based solutions.After development and validation of a reliable technique to measure ease of PFC puncture, the efficacy of therapies designed to modify PFC compliance could be assessed. The use of ultrasound mediated microbubble (UMM) disruption to act as an adjuvant to accelerate collagenase therapy in CTO was examined. A significant reduction in puncture force and an increase in the amount of collagen degraded was achieved using a combined UMM + collagenase treatment compared with collagenase therapy alone and UMM treatment alone.