Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3764_Библиотеки_им_академика_М_И_Перельмана
.pdf
18 PART I Pathology, Indications, and Review of Clinical Trials
References
1 Fefer P, Knudtson ML, Cheema AN, Galbraith PD, Osherov
AB, Yalonetsky S, Gannot S, Samuel M, Weisbrod M,
Bierstone D et al. Current perspectives on coronary
chronic total occlusions: the Canadian Multicenter
Chronic Total Occlusions Registry. J Am Coll Cardiol 2012;
59: 991–997. doi: 10.1016/j.jacc.2011.12.007.
2 Jeroudi OM, Alomar ME, Michael TT, El Sabbagh A, Patel
VG, Mogabgab O, Fuh E, Sherbet D, Lo N, Roesle M et al.
Prevalence and management of coronary chronic total occlusions in a tertiary Veterans Affairs hospital. Catheter
Cardiovasc Interv 2014; 84: 637–643. doi: 10.1002/ccd.25264.
3 Farooq V, Serruys PW, Garcia-Garcia HM, Zhang Y,
Bourantas CV, Holmes DR, Mack M, Feldman T, Morice
MC, Stahle E et al. The negative impact of incomplete
angiographic revascularization on clinical outcomes and
its association with total occlusions: the SYNTAX (Synergy
Between Percutaneous Coronary Intervention with Taxus
and Cardiac Surgery) trial. J Am Coll Cardiol 2013; 61:
282–294. doi: 10.1016/j.jacc.2012.10.017.
4 Hwang D, Park J, Yang HM, Yang S, Kang J, Han JK, Park
KW, Kang HJ, Koo BK, Kim HS. Angiographic complete
revascularization versus incomplete revascularization in
patients with diabetes mellitus. Cardiovasc Diabetol 2022;
21: 56. doi: 10.1186/s12933-022-01488-7.
5 Maeremans J, Walsh S, Knaapen P, Spratt JC, Avran A,
Hanratty CG, Faurie B, Agostoni P, Bressollette E, Kayaert P
et al. The hybrid algorithm for treating chronic total occlusions in Europe: the RECHARGE registry. J Am Coll Cardiol
2016; 68: 1958–1970. doi: 10.1016/j.jacc.2016.08.034.
6 Wu EB, Brilakis ES, Mashayekhi K, Tsuchikane E, Alaswad
K, Araya M, Avran A, Azzalini L, Babunashvili AM,
Bayani B et al. Global chronic total occlusion crossing
algorithm: JACC state-of-the-art review. J Am Coll Cardiol
2021; 78: 840–853. doi: 10.1016/j.jacc.2021.05.055.
7 Nagaraja V, Ooi SY, Nolan J, Large A, De Belder M,
Ludman P, Bagur R, Curzen N, Matsukage T, Yoshimachi
F et al. Impact of incomplete percutaneous revascularization in patients with multivessel coronary artery disease: a
systematic review and meta-analysis. J Am Heart Assoc
2016; 5. doi: 10.1161/JAHA.116.004598.
8 Srivatsa SS, Edwards WD, Boos CM, Grill DE, Sangiorgi
GM, Garratt KN, Schwartz RS, Holmes DR, Jr. Histologic
correlates of angiographic chronic total coronary artery
occlusions: influence of occlusion duration on neovascular channel patterns and intimal plaque composition. J
Am Coll Cardiol 1997; 29: 955–963. doi: 10.1016/
s0735-1097(97)00035-1.
9 Yahagi K, Kolodgie FD, Otsuka F, Finn AV, Davis HR,
Joner M, Virmani R. Pathophysiology of native coronary,
vein graft, and in-stent atherosclerosis. Nat Rev Cardiol
2016; 13: 79–98. doi: 10.1038/nrcardio.2015.164.
10 Sakakura K, Nakano M, Otsuka F, Yahagi K, Kutys R,
Ladich E, Finn AV, Kolodgie FD, Virmani R. Comparison
of pathology of chronic total occlusion with and without
coronary artery bypass graft. Eur Heart J 2014; 35: 1683–
1693. doi: 10.1093/eurheartj/eht422.
11 Rossi JE, Nair R, Ellis SG, Kapadia SR, Khatri JJ. Use of
polymer-jacketed, tapered-tip, low-force guidewires with
composite-core, dual-coil design as part of the antegrade
approach to coronary chronic total occlusions. J Invasive
Cardiol 2020; 32: 161–168.
12 Werner GS, Moehlis H, Tischer K. Management of total
restenotic occlusions. EuroIntervention 2009; 5(Suppl D):
D79–83.
13 Azzalini L, Dautov R, Ojeda S, Benincasa S, Bellini B,
Giannini F, Chavarria J, Pan M, Carlino M, Colombo A
et al. Procedural and long-term outcomes of percutaneous coronary intervention for in-stent chronic total
occlusion. JACC Cardiovasc Interv 2017; 10: 892–902.
doi: 10.1016/j.jcin.2017.01.047.
14 Miura K, Tanaka H, Kishi K, Muramatsu T, Okada H,
Oikawa Y, Kawasaki T, Yoshikawa R, Okamura A,
Tsuchikane E. Impact of timing and treatment strategy
on coronary perforation during percutaneous coronary intervention for chronic total occlusion. Am J
Cardiol 2022; 172: 26–34. doi: 10.1016/j.amjcard.
2022.02.019.
15 Mori H, Lutter C, Yahagi K, Harari E, Kutys R, Fowler
DR, Ladich E, Joner M, Virmani R, Finn AV. Pathology
of chronic total occlusion in bare-metal versus drugeluting stents: implications for revascularization. JACC
Cardiovasc Interv 2017; 10: 367–378. doi: 10.1016/j.
jcin.2016.11.005.
16 Azzalini L, Ojeda S, Karatasakis A, Maeremans J, Tanabe
M, La Manna A, Dautov R, Ybarra LF, Benincasa S,
Bellini B et al. Long-term outcomes of percutaneous
coronary intervention for chronic total occlusion in
patients who have undergone coronary artery bypass
grafting vs those who have not. Can J Cardiol 2018; 34:
310–318. doi: 10.1016/j.cjca.2017.12.016.
17 Tajti P, Karmpaliotis D, Alaswad K, Jaffer FA, Yeh RW,
Patel M, Mahmud E, Choi JW, Burke MN, Doing AH
et al. In-hospital outcomes of chronic total occlusion
percutaneous coronary interventions in patients with
prior coronary artery bypass graft surgery. Circ
Cardiovasc Interv 2019; 12: e007338. doi: 10.1161/
CIRCINTERVENTIONS.118.007338.
18 Brilakis ES, Mashayekhi K, Tsuchikane E, Abi Rafeh
N, Alaswad K, Araya M, Avran A, Azzalini L,
Babunashvili AM, Bayani B et al. Guiding principles
for chronic total occlusion percutaneous coronary
intervention. Circulation 2019; 140: 420–433. doi:
10.1161/CIRCULATIONAHA.119.039797.
3
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
CHAPTER 3
Indications and Guidelines
of PCI for CTO
Ilan Merdler, Gabriel Maluenda & Ron Waksman*
MedStar Washington Hospital Center, Washington, DC, USA
* Corresponding author
Introduction
Chronic total occlusions (CTOs) are completely
occluded coronary arteries with no flow and an estimated duration of at least 3 months. They are found in
about one-quarter of patients undergoing coronary
angiography [1, 2]. In recent years, CTO percutaneous coronary intervention (PCI) has seen the development of enhanced techniques, along with greater
equipment and operator experience, and success rates
of 80% have been reported [3]. However, a 30-day
mortality rate of over 1% and an almost 5% rate of
perforations were also reported [4]. There are 7 widely
accepted principles [5] for CTO-PCI: ischemic symptom improvement as the primary indication, in-depth
planning, microcatheters for optimal manipulation,
combination of antegrade and retrograde approaches,
efficient change of technique, specific CTO-PCI
expertise, and optimum stent expansion. In this chapter, we will discuss the indications and guidelines of
CTO-PCI and the relevant evidence.
Outcome benefits associated with
CTO-PCI
Symptom improvement is the primary indication for
CTO-PCI. Two randomized control trials [6, 7]
(Table 3.1) and several observational trials [3] have
shown improvement in symptoms in these patients.
However, randomized trials have not succeeded in
demonstrating the efficacy of CTO revascularization
for hard endpoints such as mortality, myocardial
infarction, stroke, or heart failure [8]. Thus, the main
indication for CTO-PCI currently is symptom control.
Symptom relief
Successful PCI of CTO has been associated with
important symptomatic relief when compared to
failed procedures. In the TOAST-GISE (Total
Occlusion Angioplasty Study-Societa Italiana di
Cardiologia Invasiva) multi-center study conducted
on 369 patients with CTOs > 30 days of duration,
patients with successful CTO-PCI were more frequently free of angina (88.7%) compared to patients
who had an unsuccessful procedure (75%) at 1-year
follow-up (p = 0.008) [9]. The results of the FACTOR
trial (FlowCardia’s Approach to Chronic Total
Occlusion Recanalization), conducted in 125 patients
and based on the Seattle Angina Questionnaire (SAQ)
performed at baseline and 1 month after CTO-PCI,
showed that procedural success was independently
associated with angina relief (SAQ delta among
successful and unsuccessful PCI = 9.5 points,
p = 0.019), improved physical activity (SAQ delta
=13.1 points, p= 0.001), and enhanced quality of life
(SAQ delta = 20.3 points, p < 0.001), which was
greater in symptomatic patients than in asymptomatic
patients [10]. The EuroCTO multicenter trial randomly assigned 396 patients to CTO-PCI versus optimal medical therapy alone. At 1 year, in comparison
with patients randomly assigned to medical therapy
only, CTO-PCI patients had greater improvement in
angina frequency (subscale change difference, 5.23;
95% CI, 1.75–8.71; P
scale change difference, 6.62; 95% CI, 1.78–11.46;
P = 0.007), as assessed with the SAQ [6]. The
IMPACTOR-CTO trial (Impact on Inducible
Myocardial Ischemia of Percutaneous Coronary
Intervention versus Optimal Medical Therapy in
= 0.003) and quality of life (sub-
Chronic Total Occlusions: A Guide to Recanalization, Third Edition. Edited by Ron Waksman and Shigeru Saito.
© 2024 John Wiley & Sons Ltd. Published 2024 by John Wiley & Sons Ltd.
19
20 PART I Pathology, Indications, and Review of Clinical Trials
Table 3.1 Randomized controlled trials in CTO-PCI.
Study n Design CTO success % Follow-up Primary Endpoint Results
DECISIONCTO [11]
EuroCTO [6] 396 Multicenter 87 1 year Changes in symptoms Improvement (p = 0.007)
IMPACTORCTO [7]
EXPLORE [12] 304 Multicenter 73 4 months Ejection Fraction on
REVASC [13] 205 Single Center 97 1 year Changes in myocardial
834 Multicenter 91 4 years Composite of death, MI,
stroke and revascularization
72 Single Center 83 1 year Ischemia Burden Decrease (p < 0.01)
Cardiac MRI
wall thickness
No Differences
(p = 0.86)
No differences (p = 0.6)
No differences (p = 0.57)
Patients with Right Coronary Artery Chronic Total
Occlusion) randomly assigned 94 patients (single
center) with isolated right coronary artery CTO to
CTO-PCI versus optimal medical therapy alone. At 1
year, patients undergoing CTO-PCI had a significant
reduction in ischemic burden and improvement in
6-minute walk distance and quality of life [7]. We
must also mention the randomized DECISION CTO
trial (Drug-Eluting Stent Implantation Versus
Optimal Medical Treatment in Patients with Chronic
Total Occlusion), which did not show an improvement in symptoms for CTO-PCI patients [11].
Left ventricular function
In the past, studies examining changes in ejection
fraction (EF) after CTO-PCI have shown improvement. Left ventricular (LV) angiogram follow-up performed after 6 months of successful recanalization of
CTO in a series of 95 patients found that the EF
increased from 62% to 67% (p < 0.001). No changes in
EF were noted in 8 patients found to have re-occlusion
of the CTO at angiographic follow-up [14]. A substudy of 244 patients in the Total Occlusion Study of
Canada (TOSCA) who had ventriculograms at baseline and at 6-month follow-up found a significant
improvement in EF over time (from 59% to 61%,
p = 0.003). In this series, multivariate analysis revealed
that baseline EF < 60%, duration of occlusion ≤ 6
weeks, and Canadian Cardiovascular Society (CCS)
angina class I or II were independently associated
with an improvement in EF after successful CTO-PCI
[15]. Other studies have suggested that patients who
have never had myocardial infarction (MI) or those
with evidence of residual ischemia or viable myocardium after MI are most likely to benefit from CTOPCI [16–18]. In addition, Cheng et al. showed that
wall thickening of myocardium supported by a CTO
vessel improved after CTO-PCI based on a cardiac
magnetic resonance imaging study performed 6
months after successful PCI (from 55% to 68%) [19].
This evidence suggests that imaging techniques to
assess viability/ischemia may be particularly useful in
determining the role of CTO-PCI in patients with
decreased LV function.
However, newer randomized control studies such
as the EXPLORE trial have shown a different result.
Using cardiac MRI, the EXPLORE study showed no
advantages of CTO-PCI compared with drug treatment at 4 months after the acute event [12].
Arrhythmic events and sudden cardiac
death
CTO of an infarct-related coronary artery has been
associated with higher risk of ventricular arrhythmia
[20]. In patients with CTO, low coronary blood flow
can theoretically create an arrhythmic substrate and
favor the occurrence of ventricular tachycardia. CTO
revascularization might restore blood flow in the area
close to the fibrotic scar and, thus, generate positive
remodeling and reduce ventricular arrhythmias. A
meta-analysis that assessed ventricular arrhythmias in
patients with CTO has shown that CTO is associated
with an increased risk of ventricular arrhythmia and
all-cause mortality [21]. However, not enough studies
are available to address the issue.
Reduction in need for CABG
Successful CTO-PCI appears to be associated with a
significant reduction in the need for surgical revascularization. Freedom from coronary artery bypass
grafting (CABG) was significantly higher among the
317 patients at Emory with successful CTO-PCI at 4
years’ follow-up when compared to the 163 patients
with failed PCI (87% vs 64%, p < 0.0001) [22]. In the
TOAST-GISE study, patients with successful CTOPCI had a lower rate of CABG at 1-year follow-up
(2.5% vs 15.7%, p < 0.0001). Multivariate analysis
showed that the only characteristic associated with
event-free survival was CTO-PCI success or failure
[9]. In a 5-year follow-up of 1791 patients who underwent CTO-PCI in 3 tertiary centers in the USA, South
Korea, and Italy, patients with successful CTO-PCI
CHAPTER 3 Indications and Guidelines of PCI for CTO 21
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
had significantly lower rates of CABG compared to
patients with failed CTO-PCI (3.2% vs 13.3%, p <
0.001) [23]. Among 100 CTOs in patients with CCS
angina class III or IV despite medical therapy, 47 were
successfully recanalized, and only 7 (15%) underwent
CABG. Among the 45 patients with unsuccessful,
uncomplicated procedures, 16 (36%) surgeries were
required and, among the 8 patients with complicated
procedures, 3 (38%) required CABG [24].
Survival benefit
There is no agreement regarding survival benefit in
CTO-PCI patients. The DECISION-CTO trial, which
assessed all-cause mortality, MI, revascularization,
stroke, and major adverse cardiac events (MACE),
showed no advantages in the PCI group compared to
medical treatment alone [25]. This study excluded
patients with low EF who might have benefited from
PCI. Unlike this trial, data from several registries
showed an increase in survival among patients undergoing successful CTO-PCI [26, 27]. A meta-analysis of
25 studies (28,486 patients) showed that compared with
failed procedures, successful CTO-PCIs were associated with a lower incidence of death, stroke, and CABG
and less recurrent angina [28]. We must also mention
the REVASC study, which evaluated total mortality, MI,
and repeated revascularization, at 1 year. The CTO-PCI
group in the trial had a lower risk of MACE than the
group with medical therapy alone [13].
Predictors of CTO-PCI success
When considering a CTO-PCI, careful assessment of
the chances of success appears to be particularly important, that is, balancing the risk and benefit ratio.
Although an experienced interventionalist may elect to
immediately pursue a CTO-PCI, strong consideration
should be given to deferring “ad hoc” PCI in this situation to allow for patient discussion and determination
of the appropriate strategy [29]. In this regard, known
clinical and angiographic predictors of CTO-PCI success/failure must be carefully analyzed, in addition to
cardiac computed tomography (CT) when indicated.
Angiographic predictors
Several scores were created to estimate the difficulty
of CTO-PCI. The most commonly used is the J-CTO
score, which was created in Japan using a multicenter
registry. It estimates the likelihood of successful antegrade guidewire crossing within 30 minutes based on
5 criteria (at least 1 bend of >45° in the CTO entry or
CTO body, occlusion length >20
blunt proximal stump, and previously failed attempt)
[30]. This score was validated and is also associated
with 1-year clinical outcomes [31, 32].
mm, calcification,
Other scores include the PROGRESS-CTO score,
the RECHARGE (Registry of Crossboss and Hybrid
Procedures in France, the Netherlands, Belgium, and
United Kingdom) registry score, the CL-score
(Clinical and Lesion related score), the ORA (ostial
location, collateral filling of Rentrop <2, age >75)
score, the weighted angiographic scoring model
(W-CTO score), and the CASTLE score. There are
also cardiac CT angiography-based scores, such as the
CT-RECTOR multicenter registry (Computed
Tomography Registry of Chronic Total Occlusion
Revascularization) score and the Korean Multicenter
CTO CT Registry Score [33–39]. The scores are
mostly based on angiographic findings.
Clinical predictors
Duration of the occlusion appears to be one of the
most important predictors of procedural failure.
Generally speaking, the longer the occlusion duration, the less likely is recanalization success. Occlusion
duration longer than 3–6 months has been consistently associated with procedural failure [9, 40].
Another important clinical factor that may impact the
ability to recanalize a CTO is the presence of chronic
renal failure, which predicts a worse procedural result
and significantly limits the amount of contrast used
during the intervention [41].
Tomographic predictors
Electrocardiogram-gated cardiac CT has proved to be a
very useful tool for planning CTO-PCI, allowing one to
predict the procedural success/failure likelihood, to prevent possible complications, and to reduce procedural
time, the amount of contrast used, and radiation exposure [42, 43]. Garcia-Garcia et al. identified the following predictors for CTO-PCI failure by cardiac CT
performed in 142 patients: length of the occlusion
> 15 mm, severe calcification of the occluded segment,
and blunt-stump of the entry point, particularly if
severely calcified [43]. In addition, cardiac CT allows for
the evaluation of distal vessel characteristics, collateral
vessel distribution, degree of tortuosity of the occluded
segment, and prediction of the best angle for PCI
approach. Unfortunately, due to the amount of required
contrast and radiation associated with cardiac CT, its
use cannot be routinely recommended, but does appear
to be mandatory in patients with unfavorable angiographic anatomy and/or with prior failed CTO-PCI [2].
CTO-PCI techniques – planning the
PCI strategy
Important advances in CTO-PCI technique, including dedicated CTO wires, the use of support catheters,
the spread of drug-eluting stent technology, and the
22 PART I Pathology, Indications, and Review of Clinical Trials
development of special devices for the “retrograde”
approach, have permitted significant improvements
in CTO-PCI recanalization efficacy and safety.
Whenever collaterals are present, bilateral injections
are recommended to allow for simultaneous antegrade and retrograde filling of the target vessel.
General concepts on antegrade and
retrograde techniques
Generally, the antegrade approach is attempted first.
Tapered hydrophilic wires are initially used with the
intention of crossing though microchannels. If this
primary approach fails, progressive wire tip stiffness
should be tried (3–9 g wires) followed by tapered,
hydrophilic 9–20 g wires if this fails. If the wire is
advanced into the subintimal space, it should be left in
place at the time that a second similar wire is used
(“parallel wire” technique). If the second wire moves
subintimally, the first wire is pulled and an attempt to
cross (“see-saw wire” technique) is made [44]. The use
of a microcatheter, placed near the lesion, may be
helpful to increase the support and the penetration
power of the guidewire [5]. The retrograde approach
uses collateral channels to cross the CTO. Septal,
straight channels, with visible connection to the distal
vessel, are ideal for this approach. Atrial and epicardial collaterals are potentially useful but are more predisposed to dissection and perforation. Once the
collateral has been identified, selective injection must
be performed using microcatheters. If the collateral
channel appears to be suitable, a Corsair channel dilator is advanced over the wire. Subsequently, different
techniques (including simple retrograde wire cross,
kissing wire cross, controlled antegrade, and retrograde tracking [CART] and reverse CART) can be
attempted to cross the distal CTO cap [45].
In-hospital outcomes using current
CTO-PCI techniques
Using contemporary techniques, the J-CTO Registry
reported a success rate of 88.6% in first-attempt cases in
528 treated CTO lesions of 498 patients [32]. These
results were achieved, however, with a median fluoroscopy time of 45 minutes and a mean contrast volume of
293 ml. In addition, the frequency of perforation was
7.2% with antegrade approach and 13.6% with retrograde approach. Clinically significant tamponade was
seen in only 0.4% collectively [32]. The results of the
multi-center ERCTO (European Registry of Chronic
Total Occlusion) reported an overall success rate of
82.9% of 1983 treated CTO lesions in 1914 patients
(83.2% antegrade vs 64.5% retrograde, p < 0.001) [46].
These results were achieved, however, with a mean
fluoroscopy time of 42.3 minutes and a total contrast
volume of 313 ml. In addition, the frequency of perfo-
ration was 2.1% with antegrade approach and 4.7%
with retrograde approach. The tamponade rate was
only 0.5% [46]. Using techniques from Japan, a study
conducted in two US centers reported the outcomes of
636 consecutive patients undergoing CTO-PCI
between 2005 and 2008, comparing the results of highvolume operators (>75 total CTO-PCI cases and > 20
retrograde attempts during the study period) to nonhigh-volume operators. The overall technical success
was 58.9% for non-high-volume operators and 75.2%
for high-volume operators (p < 0.001) [47]. The technical success rate did not change for non-high-volume
operators, but for high-volume operators, it increased
to 90% over time (p < 0.001 for trend, 94.4% for retrograde and 85.7% for antegrade approach). These results
were achieved with a mean fluoroscopy time of 45 min
and 42 min (p = ns), total contrast volume of 433 ml vs
342 ml (p < 0.001), and cardiac tamponade rates of
0.97% vs 0.82% (p = ns), comparing non-high-volume
and high-volume operators, respectively [47].
Guidelines
The 2018 European Society of Cardiology (ESC)/
European Association of Cardiothoracic Surgery guidelines on myocardial revascularization CTO-PCI carry
a class IIA/level of evidence B recommendation:
“Percutaneous recanalization of CTOs should be considered in patients with angina resistant to medical
therapy or with large area of documented ischemia in
the territory of the occluded vessel” [48]. The 2021
American Heart Association (AHA) guidelines for coronary artery revascularization carry a class 2B/level of
evidence B–R recommendation: “In patients with suitable anatomy who have refractory angina on medical
therapy, after treatment of non-CTO lesions, the benefit
of PCI of a CTO to improve symptoms is uncertain” [2].
A summary of the guidelines is shown in Table 3.2.
The AHA guidelines [2] raise some controversy,
and the latest guidelines have downgraded the indication class from 2A to 2B. As mentioned previously in
this chapter, the 30-day mortality rate is over 1% and
the perforations rate reaches almost 5% [4].
Retrospective data show good outcomes in treating
CTO, but data from randomized controlled trials
(RCTs) do not demonstrate impressive results. The
AHA guidelines, thus, recommend discussing all
options with the patients and explaining all limitations and benefits. The EXPLORE trial [12] and
REVASC trial [13] did not show improvement of EF
compared to medical therapy when treating CTOs.
The EURO CTO Trial [6], which did show a reduction in angina frequency, was contradicted by the
DECISION-CTO [11] trial. We assume that the
authors of the guidelines have placed equal weight on
CHAPTER 3 Indications and Guidelines of PCI for CTO 23
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
Table 3.2 Summary of Guidelines.
Guidelines Indication Class Level of Evidence Year Clinical Indication Required
ESC 2A B 2018 Resistant Angina Documented large area of ischemia
AHA 2B B–R 2021 Refractory
Angina
Suitable anatomy and treatment
of non-CTO lesions
these two trials; however, many criticize the methodology of the DECISION-CTO trial (difficulties enrolling patients, most patients from a single center,
non-negligible crossover, etc.) [49]. Also, most realworld patients are not enrolled in clinical trials. In
order for future guidelines writers to want to increase
the indication level, a reduction in complications
must be demonstrated in future RCTs. Also, evidence
of both symptomatic relief and hard cardiovascular
outcomes must be shown.
Conclusions
Successful CTO recanalization has been shown to be
beneficial by leading to reduced need for CABG,
improved EF, and improved long-term survival.
Nonetheless, the main source of evidence comes from
observational, retrospective, non-randomized series,
with limited information regarding the potential baseline differences among successful and unsuccessful
cohorts. Therefore, the only current indication,
according to American and European guidelines for
CTO-PCI, is symptomatic relief. Factors associated
with CTO-PCI procedural failure include multi-vessel
disease, presence of bridging collaterals, moderate to
severe calcification, longer CTO length, and longer
CTO duration. Longer stented length and lower minimal lumen diameter following PCI have been shown
to be associated with a higher incidence of binary
restenosis [50]. As technical success improves and
long-term follow-up of patients verifies the benefits of
CTO-PCI, interest in this procedure is expected to
rise. Much of the current evidence is retrospective and
is limited by small patient numbers, but the increasing
enthusiasm is bound to lead to future well-designed
trials that should solidify our knowledge of the factors
important to procedural success and sustained patency.
References
1 Sabatine MS. Effect of clopidogrel pretreatment before
percutaneous coronary intervention in patients with
ST-elevation myocardial infarction treated with fibrinolytics the PCI-CLARITY study. JAMA 2005; 294: 1224.
2 Lawton JS, Tamis-Holland JE, Bangalore S, Bates ER,
Beckie TM, Bischoff JM, Bittl JA, Cohen MG, DiMaio JM,
Don CW, Fremes SE, Gaudino MF, Goldberger ZD, Grant
MC, Jaswal JB, Kurlansky PA, Mehran R, Metkus TS,
Nnacheta LC, Rao SV, Sellke FW, Sharma G, Yong CM,
Zwischenberger BA. 2021 ACC/AHA/SCAI guideline for
coronary artery revascularization. J Am Coll Cardiol 2022;
79: e21–e129.
3 Sapontis J, Salisbury AC, Yeh RW, Cohen DJ, Hirai T,
Lombardi W, McCabe JM, Karmpaliotis D, Moses J,
Nicholson WJ, Pershad A, Wyman RM, Spaedy A, Cook
S, Doshi P, Federici R, Thompson CR, Marso SP, Nugent
K, Gosch K, Spertus JA, Grantham JA. Early procedural
and health status outcomes after chronic total occlusion
angioplasty. JACC Cardiovasc Interv 2017; 10:
1523–1534.
Tajti P, Burke MN, Karmpaliotis D, Alaswad K, Jaffer FA,
4
Yeh RW, Patel M, Mahmud E, Choi JW, Doing AH, Datilo
P, Toma C, Smith AJC, Uretsky B, Holper
E, Garcia S, Krestyaninov O, Khelimskii D, Koutouzis
M, Tsiafoutis I, Moses JW, Lembo NJ, Parikh M, Kirtane
AJ, Ali ZA, Doshi D, Jaber W, Samady H, Rangan BV,
Xenogiannis I, Ungi I, Banerjee S, Brilakis ES. Prevalence
and outcomes of percutaneous coronary interventions for
ostial chronic total occlusions: insights from a multicenter
chronic total occlusion registry. Can J Cardiol 2018; 34:
1264–1274.
5
Brilakis ES, Mashayekhi K, Tsuchikane E, Abi Rafeh N,
Alaswad K, Araya M, Avran A, Azzalini L, Babunashvili
AM, Bayani B, Bhindi R, Boudou N, Boukhris M, Božinović
NŽ, Bryniarski L, Bufe A, Buller CE, Burke MN, Büttner HJ,
Cardoso P, Carlino M, Christiansen EH, Colombo A, Croce
K, Damas de los Santos F, De Martini T, Dens J, Di Mario C,
Dou K, Egred M, ElGuindy AM, Escaned J, Furkalo
S, Gagnor A, Galassi AR, Garbo R, Ge J, Goel PK, Goktekin
O, Grancini L, Grantham JA, Hanratty C, Harb S, Harding
SA, Henriques JPS, Hill JM, Jaffer FA, Jang Y, Jussila R,
Kalnins A, Kalyanasundaram A, Kandzari DE, Kao
H-L, Karmpaliotis D, Kassem HH, Knaapen P, Kornowski R,
Krestyaninov O, Kumar AVG, Laanmets P, Lamelas P, Lee
S-W, Lefevre T, Li Y, Lim S-T, Lo S, Lombardi W, McEntegart
M, Munawar M, Navarro Lecaro JA, Ngo HM, Nicholson W,
Olivecrona GK, Padilla L, Postu M, Quadros A, Quesada
FH, Prakasa Rao VS, Reifart N, Saghatelyan M, Santiago R,
Sianos G, Smith E, Spratt JC, Stone GW, Strange
JW, Tammam K, Ungi I, Vo M, Vu VH, Walsh S, Werner GS,
Wollmuth JR, Wu EB, Wyman RM, Xu B, Yamane M, Ybarra
LF, Yeh RW, Zhang Q, Rinfret S. Guiding principles for
chronic total occlusion percutaneous coronary intervention:
a global expert consensus document. Circulation 2019; 140:
420–433.
Werner GS, Martin-Yuste V, Hildick-Smith D, Boudou N,
6
Sianos G, Gelev V, Rumoroso JR, Erglis A, Christiansen
EH, Escaned J, Di Mario C, Hovasse T, Teruel L, Bufe A,
24 PART I Pathology, Indications, and Review of Clinical Trials
Lauer B, Bogaerts K, Goicolea J, Spratt JC, Gershlick AH,
Galassi AR, Louvard Y, EUROCTO trial investigators. A
randomized multicentre trial to compare revascularization with optimal medical therapy for the treatment of
chronic total coronary occlusions. Eur Heart J 2018; 39:
2484–2493.
7 Obedinskiy AA, Kretov EI, Boukhris M, Kurbatov
VP, Osiev AG, Ibn Elhadj Z, Obedinskaya NR, Kasbaoui
S, Grazhdankin IO, Prokhorikhin AA, Zubarev DD,
Biryukov A, Pokushalov E, Galassi AR, Baystrukov VI.
The IMPACTOR-CTO trial. JACC Cardiovasc Interv
2018; 11: 1309–1311.
8 Vescovo GM, Zivelonghi C, Scott B, Agostoni P.
Percutaneous coronary intervention for chronic total
occlusion. US Cardiol Rev 2020; 14: e11.
9 Olivari Z, Rubartelli P, Piscione F, Ettori F, Fontanelli A,
Salemme L, Giachero C, Di Mario C, Gabrielli G,
Spedicato L, Bedogni F. Immediate results and one-year
clinical outcome after percutaneous coronary interventions in chronic total occlusions. J Am Coll Cardiol 2003;
41: 1672–1678.
10 Grantham JA, Jones PG, Cannon L, Spertus JA.
Quantifying the early health status benefits of successful
chronic total occlusion recanalization: results from the
FlowCardia’s Approach to Chronic Total Occlusion
Recanalization (FACTOR) trial. Circ Cardiovasc Qual
Outcomes 2010; 3: 284–290.
11 Lee S-W, Lee PH, Ahn J-M, Park D-W, Yun S-C, Han S,
Kang H, Kang S-J, Kim Y-H, Lee CW, Park S-W, Hur
SH, Rha S-W, Her S-H, Choi SW, Lee B-K, Lee N-H, Lee
J-Y, Cheong -S-S, Kim MH, Ahn Y-K, Lim SW, Lee S-G,
Hiremath S, Santoso T, Udayachalerm W, Cheng JJ,
Cohen DJ, Muramatsu T, Tsuchikane E, Asakura Y, Park
S-J. Randomized trial evaluating percutaneous coronary intervention for the treatment of chronic total
occlusion: the DECISION-CTO trial. Circulation 2019;
139: 1674–1683.
12 Henriques JPS, Hoebers LP, Råmunddal T, Laanmets
P, Eriksen E, Bax M, Ioanes D, Suttorp MJ, Strauss
BH, Barbato E, Nijveldt R, van Rossum AC, Marques
KM., Elias J, van Dongen IM, Claessen BEPM,
Tijssen JG, van der Schaaf RJ, Henriques JPS, van
der Schaaf R, Tijssen JGP, Zijlstra F, de Boer M-J,
Michels R, Meuwissen M, Agostoni P, van
Houwelingen KG, Verberne HJ, Hirsch A, Henriques
JPS, Piek JJ, de Winter RJ, Koch KT, Vis MM, Baan J,
Wykrzykowska J, Råmunddal T, Ioanes D, Laanmets
P, van der Schaaf RJ, Slagboom T, Amoroso G,
Eriksen E, Tuseth V, Bax M, Schotborgh CE, Suttorp
MJ, Strauss BH, Barbato E, Marques KM., Bertrand
O, Meuwissen M, van der Ent M, Koolen J.
Percutaneous intervention for concurrent chronic
total occlusions in patients with STEMI. J Am Coll
Cardiol 2016; 68: 1622–1632.
13 Mashayekhi K, Nührenberg TG, Toma A, Gick M, Ferenc
M, Hochholzer W, Comberg T, Rothe J, Valina
CM, Löffelhardt N, Ayoub M, Zhao M, Bremicker J,
Jander N, Minners J, Ruile P, Behnes M, Akin I, Schäufele
T, Neumann F-J, Büttner HJ. A randomized trial to assess
regional left ventricular function after stent implantation
in chronic total occlusion. JACC Cardiovasc Interv 2018;
11: 1982–1991.
14 Sirnes P. Improvement in left ventricular ejection fraction
and wall motion after successful recanalization of chronic
coronary occlusions. Eur Heart J 1998; 19: 273–281.
15 Dzavik V, Carere RG, Mancini GBJ, Cohen EA, Catellier
D, Anderson TE, Barbeau G, Lazzam C, Title LM, Berger
PB, Labinaz M, Te o KK, Buller CE. Predictors of improvement in left ventricular function after percutaneous
revascularization of occluded coronary arteries: a report
from the Total Occlusion Study of Canada (TOSCA). Am
Heart J 2001; 142: 301–308.
16 Chung C-M, Nakamura S, Tanaka K, Tanigawa J, Kitano
K, Akiyama T, Matoba Y, Katoh O. Effect of recanalization of chronic total occlusions on global and regional
left ventricular function in patients with or without
previous myocardial infarction. Cathet Cardiovasc
Intervent 2003; 60: 368–374.
17 Baks T, van Geuns R-J, Duncker DJ, Cademartiri F,
Mollet NR, Krestin GP, Serruys PW, de Feyter PJ.
Prediction of left ventricular function after drug-eluting
stent implantation for chronic total coronary occlusions.
J Am Coll Cardiol 2006; 47: 721–725.
18 Kirschbaum SW, Baks T, van den Ent M, Sianos G,
Krestin GP, Serruys PW, de Feyter PJ, van Geuns R-JM.
Evaluation of left ventricular function three years after
percutaneous recanalization of chronic total coronary
occlusions. Am J Card 2008; 101: 179–185.
19 Cheng ASH, Selvanayagam JB, Jerosch-Herold M, van
Gaal WJ, Karamitsos TD, Neubauer S, Banning AP.
Percutaneous treatment of chronic total coronary occlusions improves regional hyperemic myocardial blood
flow and contractility. JACC Cardiovasc Interv 2008; 1:
44–53.
20 Nombela-Franco L, Mitroi CD, Fernández-Lozano I,
García-Touchard A, Toquero J, Castro-Urda
V, Fernández-Diaz JA, Perez-Pereira E, Beltrán-Correas
P, Segovia J, Werner GS, Javier G, Luis A-P. Ventricular
arrhythmias among implantable cardioverter-defibrillator recipients for primary prevention: impact of chronic
total coronary occlusion (VACTO Primary Study). Circ
Arrhythm Electrophysiol 2012; 5: 147–154.
21 Chi WK, Gong M, Bazoukis G, Yan BP, Letsas KP, Liu T,
Baranchuk A, Nombela-Franco L, Dong M, Tse G.
Impact of coronary artery chronic total occlusion on
arrhythmic and mortality outcomes. JACC Clin
Electrophysiol 2018; 4: 1214–1223.
22 Ivanhoe RJ, Weintraub WS, Douglas JS, Lembo NJ,
Furman M, Gershony G, Cohen CL, King SB. Percutaneous
transluminal coronary angioplasty of chronic total occlusions. Primary success, restenosis, and long-term clinical
follow-up. Circulation 1992; 85: 106–115.
23 Mehran R, Claessen BE, Godino C, Dangas GD, Obunai
K, Kanwal S, Carlino M, Henriques JPS, Di Mario C, Kim
Y-H, Park S-J, Stone GW, Leon MB, Moses JW, Colombo
A. Long-term outcome of percutaneous coronary intervention for chronic total occlusions. JACC Cardiovasc
Interv 2011; 4: 952–961.
24 Stewart JT, Denne L, Bowker TJ, Mulcahy DA, Williams
MG, Buller NP, Sigwart U, Rickards AF. Percutaneous
CHAPTER 3 Indications and Guidelines of PCI for CTO 25
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
transluminal coronary angioplasty in chronic coronary
artery occlusion. J Am Coll Cardiol 1993; 21: 1371–1376.
Galassi AR, Boukhris M, Toma A, Elhadj ZI, Laroussi L,
25
Gaemperli O, Behnes M, Akin I, Lüscher TF, Neumann
FJ, Mashayekhi K. Percutaneous coronary intervention
of chronic total occlusions in patients with low left ventricular ejection fraction. JACC Cardiovasc Interv 2017;
10: 2158–2170.
26
Choi IJ, Koh Y-S, Lim S, Choo EH, Kim JJ, Hwang B-H,
Kim T-H, Seo SM, Kim CJ, Park M-W, Shin DI, Choi Y-S,
Park H-J, Her S-H, Kim D-B, Park CS, Lee J-M, Moon
KW, Chang K, Kim HY, Yoo K-D, Jeon DS, Chung
W-S, Ahn Y, Jeong MH, Seung K-B, Kim P-J. Impact of
percutaneous coronary intervention for chronic total
occlusion in non–infarct-related arteries in patients with
acute myocardial infarction (from the COREA-AMI
Registry). Am J Card 2016; 117: 1039–1046.
27
Park JY, Choi BG, Rha S-W, Kang TS, Choi CU, Yu CW,
Gwon H-C, Chae I-H, Kim H-S, Park HS, Lee S-H, Kim
M-H, Hur S-H, Jang Y. Chronic total occlusion intervention of the non-infarct-related artery in acute myocardial
infarction patients: the Korean multicenter chronic total
occlusion registry. Coron Artery Dis 2018; 29: 495–501.
Christakopoulos GE, Christopoulos G, Carlino M,
28
Jeroudi OM, Roesle M, Rangan BV, Abdullah S, Grodin J,
Kumbhani DJ, Vo M, Luna M, Alaswad K, Karmpaliotis
D, Rinfret S, Garcia S, Banerjee S, Brilakis ES. Metaanalysis of clinical outcomes of patients who underwent
percutaneous coronary interventions for chronic total
occlusions. Am J Card 2015; 115: 1367–1375.
29
Nallamothu BK, Krumholz HM. Putting ad hoc PCI on
pause. JAMA 2010; 304: 2059–2060.
30 Morino Y, Abe M, Morimoto T, Kimura T, Hayashi Y,
Muramatsu T, Ochiai M, Noguchi Y, Kato K, Shibata
Y, Hiasa Y, Doi O, Yamashita T, Hinohara T, Tanaka H,
Mitsudo K. Predicting successful guidewire crossing
through chronic total occlusion of native coronary
lesions within 30 minutes. JACC Cardiovasc Interv 2011;
4: 213–221.
Christopoulos G, Wyman RM, Alaswad K, Karmpaliotis
31
D, Lombardi W, Grantham JA, Yeh RW, Jaffer FA, Cipher
DJ, Rangan BV, Christakopoulos GE, Kypreos MA,
Lembo N, Kandzari D, Garcia S, Thompson CA, Banerjee
S, Brilakis ES. Clinical utility of the Japan–Chronic Total
Occlusion Score in coronary chronic total occlusion
interventions: results from a multicenter registry. Circ
Cardiovasc Interv 2015; 8: e002171.
32 Tanaka H, Morino Y, Abe M, Kimura T, Hayashi Y,
Muramatsu T, Ochiai M, Noguchi Y, Kato K, Shibata
Y, Hiasa Y, Doi O, Yamashita T, Morimoto T, Hinohara T,
Fujii T, Mitsudo K. Impact of J-CTO score on procedural
outcome and target lesion revascularisation after percutaneous coronary intervention for chronic total occlusion: a substudy of the J-CTO Registry (Multicentre CTO
Registry in Japan). EuroIntervention 2016; 11: 981–988.
33 Christopoulos G, Kandzari DE, Yeh RW, Jaffer FA,
Karmpaliotis D, Wyman MR, Alaswad K, Lombardi
W, Grantham JA, Moses J, Christakopoulos G, Tarar
MNJ, Rangan BV, Lembo N, Garcia S, Cipher D,
Thompson CA, Banerjee S, Brilakis ES. Development
and validation of a novel scoring system for predicting
technical success of chronic total occlusion percutaneous
coronary interventions. JACC Cardiovasc Interv 2016;
9: 1–9.
Maeremans J, Spratt JC, Knaapen P, Walsh S, Agostoni P,
34
Wilson W, Avran A, Faurie B, Bressollette E, Kayaert P,
Bagnall AJ, Smith D, McEntegart MB, Smith WHT, Kelly
P, Irving J, Smith EJ, Strange JW, Dens J. Towards a contemporary, comprehensive scoring system for determining technical outcomes of hybrid percutaneous
chronic total occlusion treatment: the RECHARGE
score: the RECHARGE score for CTO-PCI. Catheter
Cardiovasc Interv 2018; 91: 192–202.
Alessandrino G, Chevalier B, Lefèvre T, Sanguineti F,
35
Garot P, Unterseeh T, Hovasse T, Morice M-C, Louvard Y.
A clinical and angiographic scoring system to predict the
probability of successful first-attempt percutaneous
coronary intervention in patients with total chronic
coronary occlusion. JACC Cardiovasc Interv 2015; 8:
1540–1548.
36
Galassi AR, Boukhris M, Azzarelli S, Castaing M, Marzà
F, Tomasello SD. Percutaneous coronary revascularization for chronic total occlusions. JACC Cardiovasc Interv
2016; 9: 911–922.
37
Ellis SG, Burke MN, Murad MB, Graham JJ, Badawi R,
Toma C, Meltser H, Nair R, Buller C, Whitlow PL.
Predictors of successful hybrid-approach chronic total
coronary artery occlusion stenting. JACC Cardiovasc
Interv 2017; 10: 1089–1098.
38
Szijgyarto Z, Rampat R, Werner GS, Ho C, Reifart N,
Lefevre T, Louvard Y, Avran A, Kambis M, Buettner H-J,
Di Mario C, Gershlick A, Escaned J, Sianos G, Galassi
A, Garbo R, Goktekin O, Meyer-Gessner M, Lauer B,
Elhadad S, Bufe A, Boudou N, Sievert H, Martin-Yuste V,
Thuesen L, Erglis A, Christiansen E, Spratt J, Bryniarski
L, Clayton T, Hildick-Smith D. Derivation and validation
of a chronic total coronary occlusion intervention procedural success score from the 20,000-patient EuroCTO
registry. JACC Cardiovasc Interv 2019; 12: 335–342.
Opolski MP, Achenbach S, Schuhbäck A, Rolf A,
39
Möllmann H, Nef H, Rixe J, Renker M, Witkowski
A, Kepka C, Walther C, Schlundt C, Debski A, Jakubczyk
M, Hamm CW. Coronary computed tomographic prediction rule for time-efficient guidewire crossing through
chronic total occlusion. JACC Cardiovasc Interv 2015; 8:
257–267.
40 Tan KH, Sulke N, Taub NA, Watts E, Karani S, Sowton E.
Determinants of success of coronary angioplasty in
patients with a chronic total occlusion: a multiple logistic
regression model to improve selection of patients. Heart
1993; 70: 126–131.
41 Osten MD, Ivanov J, Eichhofer J, Seidelin PH, Ross JR,
Barolet A, Horlick EM, Ing D, Schwartz L, Mackie
K, Džavík V. Impact of renal insufficiency on angiographic, procedural, and in-hospital outcomes following
percutaneous coronary intervention. Am J Card 2008;
101: 780–785.
42 Mollet NR, Hoye A, Lemos PA, Cademartiri F, Sianos G,
McFadden EP, Krestin GP, Serruys PW, de Feyter PJ.
Value of preprocedure multislice computed tomographic
26 PART I Pathology, Indications, and Review of Clinical Trials
coronary angiography to predict the outcome of percutaneous recanalization of chronic total occlusions. Am J
Card 2005; 95: 240–243.
43 Garcia-Garcia H, van Mieghem C, Gonzalo N, Meijboom
W, Weustink A, Onuma Y, Mollet N, Schultz C, Meliga E,
van der Ent M, Sianos G, Goedhart D, den Boer A, de
Feyter P, Serruys P. Computed Tomography in Total
coronary Occlusions (CTTO Registry): radiation
exposure and predictors of successful percutaneous
intervention. EuroIntervention 2009; 4: 607–616.
44 Ochiai M, Ashida K, Araki H, Ogata N, Okabayashi H,
Obara C. The latest wire technique for chronic total
occlusion. Ital Heart J 2005; 6: 489–493.
45 Sumitsuji S, Inoue K, Ochiai M, Tsuchikane E, Ikeno F.
Fundamental wire technique and current standard
strategy of percutaneous intervention for chronic total
occlusion with histopathological insights. JACC
Cardiovasc Interv 2011; 4: 941–951.
46 Galassi AR, Tomasello SD, Reifart N, Werner GS,
Sianos G, Bonnier H, Sievert H, Ehladad S, Bufe
A, Shofer J, Gershlick A, Hildick-Smith D, Escaned J,
Erglis A, Sheiban I, Thuesen L, Serra A, Christiansen
E, Buettner A, Costanzo L, Barrano G, Di Mario C.
In-hospital outcomes of percutaneous coronary intervention in patients with chronic total occlusion:
insights from the ERCTO (European Registry of
Chronic Total Occlusion) registry. EuroIntervention
2011; 7: 472–479.
47 Thompson CA, Jayne JE, Robb JF, Friedman BJ, Kaplan
AV, Hettleman BD, Niles NW, Lombardi WL. Retrograde
techniques and the impact of operator volume on percutaneous intervention for coronary chronic total occlusions. JACC Cardiovasc Interv 2009; 2: 834–842.
48 Neumann F-J, Sousa-Uva M, Ahlsson A, Alfonso F,
Banning AP, Benedetto U, Byrne RA, Collet J-P, Falk
V, Head SJ, Jüni P, Kastrati A, Koller A, Kristensen SD,
Niebauer J, Richter DJ, Seferović PM, Sibbing D,
Stefanini GG, Windecker S, Yadav R, Zembala MO, ESC
Scientific Document Group, Wijns W, Glineur D,
Aboyans V, Achenbach S, Agewall S, Andreotti
F, Barbato E, Baumbach A, Brophy J, Bueno H, Calvert
PA, Capodanno D, Davierwala PM, Delgado V, Dudek
D, Freemantle N, Funck-Brentano C, Gaemperli O,
Gielen S, Gilard M, Gorenek B, Haasenritter J, Haude M,
Ibanez B, Iung B, Jeppsson A, Katritsis D, Knuuti J, Kolh
P, Leite-Moreira A, Lund LH, Maisano F, Mehilli
J, Metzler B, Montalescot G, Pagano D, Petronio AS,
Piepoli MF, Popescu BA, Sádaba R, Shlyakhto E, Silber S,
Simpson IA, Sparv D, Tavilla G, Thiele H, Tousek P, Van
Belle E, Vranckx P, Witkowski A, Zamorano JL, Roffi M,
Windecker S, Aboyans V, Agewall S, Barbato E, Bueno
H, Coca A, Collet J-P, Coman IM, Dean V, Delgado V,
Fitzsimons D, Gaemperli O, Hindricks G, Iung B, Jüni P,
Katus HA, Knuuti J, Lancellotti P, Leclercq C, McDonagh
TA, Piepoli MF, Ponikowski P, Richter DJ, Roffi M,
Shlyakhto E, Sousa-Uva M, Simpson IA, Zamorano
JL, Pagano D, Freemantle N, Sousa-Uva M, Chettibi M,
Sisakian H, Metzler B, İbrahimov F, Stelmashok VI,
Postadzhiyan A, Skoric B, Eftychiou C, Kala P, Terkelsen
CJ, Magdy A, Eha J, Niemelä M, Kedev S, Motreff P,
Aladashvili A, Mehilli J, Kanakakis I-G, Becker
D, Gudnason T, Peace A, Romeo F, Bajraktari G,
Kerimkulova A, Rudzītis A, Ghazzal Z, Kibarskis A,
Pereira B, Xuereb RG, Hofma SH, Steigen TK, Witkowski
A, de Oliveira EI, Mot S, Duplyakov D, Zavatta M,
Beleslin B, Kovar F, Bunc M, Ojeda S, Witt N, Jeger
R, Addad F, Akdemir R, Parkhomenko A, Henderson R.
2018 ESC/EACTS guidelines on myocardial revascularization. Eur Heart J 2019; 40: 87–165.
49 Karmpaliotis D, Masoumi A. Retrograde chronic total
occlusion percutaneous coronary interventions. JACC
Cardiovasc Interv 2022; 15: 843–845.
50 Akboga MK, Yilmaz S. Predictors of in-stent restenosis.
Angiology 2019; 70: 279–279.
II
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
PART II
Imaging
Соседние файлы в папке Библиотека им академика М.И. Перельмана