Final Desertation

8/9/2019 Final Desertation

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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 &acute

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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75

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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77

CONCLUSION

REFERENCES

-. Irfan


78/96

78

Intervention in Chronic Total Coronary Occlusion, Int

eart ; 1##5N 0--/-.

). Moung ;, Lee , Choe , Moo , ;unghan M, yung

oon C. The feasibility of percutaneous transradial

coronary intervention for chronic total occlusion.

Monsei 3ed ; 1##5N 6"Q 50# / 0".

6.


79/96

79

$all motion after successful recanali2ation of chronic

coronary occlusion. Eu eart ; -0N-N1")B0-.

". Ma/ling , hou/li =, Huan/min ;, Mi L, ;ian , Ming/

yang 3, o L. Percutaneous coronary intervention for

chronic total occlusion in -15)patientsN a single

center report. Chinese 3ed ; 1##5N --&-6(Q --5*/

--"#.

0.


80/96

80

effectiveness in health and medicine. ;'3'.

-5N1"5Q-1*)/0.

--. ulasmaa , Tunstall/Pedoe , Dobson ',

:ortmann , ans , Tolonen , et al. Estimation of

contribution of changes in classic factors in coronary/

event rates across the =O 3OJIC' Project

populations. Lancet. 1###N)**Q5"*/0-.

-1. Popma ;;. Coronary angiography and

intravascular ultrasound imaging. InQ ipes DP, Libby

P, ono$ 8O, raun$ald E, editors. raun$ald eart

Disease, ' te!tboo% of cardiovascular medicine. Aol 1.

"th ed. K'Q =..aundersN 1##*N -0Q61)/**.)*.

-). :ye =. 'merican cardiologyQ the history of a

specialty and its college. altimore. The ;ohns op%in

Kniversity Press, -5.

-6. 3eier . Percutaneous coronary intervention.

InQ Topol E;. Te!tboo% of cardiovascular medicine. 1nd

ed. Lippincott =illiams U =il%ins. K'. Philadelphia.

1##1N0#Q-55*/"5.
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Fortmann%20S%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlushttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Sans%20S%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlushttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Tolonen%20H%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlushttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Fortmann%20S%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlushttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Sans%20S%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlushttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Tolonen%20H%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlus


81/96

81

-*. ing III . 'ngioplasty from bench to bedside

to bench. Circulation. -5N)Q-51-/1.

-5.


82/96

82

1#.


83/96

83

rural and urban populations of north India. Eur eart

;. -"N-0Q-"15/)*.

1*. Aan den oogen PC, :es%ens E;, Jegel%er%e J;,

3enotti ', Jissinen ', romhout D, et al. The relation

bet$een blood pressure and mortality due to

coronary heart disease among men in different parts

of the $orld. even Countries tudy 8esearch


84/96

84

yearsQ cross/sectional surveys of $aist circumference.

3;. 1##)N)15Q516/0.

)#. no$ler =C, Pettitt D;, aad 3:, ennett P.

Diabetes mellitus in the Pima IndiansQ incidence, ris%

factors and pathogenesis. Diabetes 3etab 8ev.

-#N5Q-/.

)-. arris 3I, :legal 3, Co$ie CC, Eberhardt 3,


85/96

85

)6. :o! 'C, 8eed


86/96

86

). onnenblic% E. Aelocity of contraction as a

determinant of myocardial o!ygen consumption. 'm ;

Physiol. -5*N1#Q-/1).

6#. Phibbs , 3arcus :, 3arriott ;C, et al. H/$ave

versus non/H/$ave myocardial infarctionQ a

meaningless distinction. ; 'm Coll Cardiol. -N))Q

)"5.

6-. oersma E, 3ercado J, Poldermans D, et al.

'cute myocardial infarction. Lancet. 1##)N)5-Q06"/

6.

61. Libby P. Current concepts of the pathogenesis of

acute coronary syndromes. Circulation.

1##-N-#6Q)5*/50.

6). :uster A, Corti 8, :ayad ', et al. Integration of

vascular biology and magnetic reasonance imaging in

the understanding of atherothrombosis and acute

coronary syndromes. ; Thromb aemost.

1##)N-Q-6-#/-6.


87/96

87

66. 3ale% '3, 'lper L, I2umo . emodynamic

shear stress and its role in atherosclerosis. ;'3'.

-N101Q1#)*/)".

6*. 8osenberg 8D, 'ird =C. Aascular/bed/specific

hemostasis and hypercoagulable states. J Engl ; 3ed.

-N)6#Q-***/*0.

65. 'rdissino D, 3erlini P', 'riens 8, et al. Tissue/

factor antigen and activity in human coronary

atherosclerotic pla@ues. Lancet. -"N)6Q"5/"#.

6". loner 8', Leor ;. natural disaster plus $a%e/up

timeQ a deadly combination of triggers. 'm eart ;.

-N-)"Q""/0).

60.


88/96

88

6. 'ntman E3, et al. 'CC+'' guidelines for the

management of patients $ith T/elevation myocardial

infarction. 1##6

&httpQ++$$$.acc.org+clinical+guidelines+stemi+inde!.ht

m(.

*#. raun$ald E, 'ntman E3, easley ;=, et al.

'CC+'' 1##1 guideline update for the management

of patients $ith unstable angina and non/T/segment

elevation myocardial infarction B summary articleQ a

report of the 'merican College of

Cardiology+'merican eart 'ssociation tas% force on

practice guidelines &Committee on the 3anagement of

Patients $ith Knstable 'ngina(. ; 'm Coll Cardiol.

1##1N6#Q-)55/5".

*-. Pedoe/Tunstall , ullasmaa , 'mouyel P, et al.

3yocardial infarction and coronary deaths in the

=orld ealth Organi2ation 3OJCI' Project.

Circulation. -6N#Q*0)/0*.

*1. 8av%ilde ;, order 3,


89/96

89

serum troponin T in suspected acute myocardial

infarction. cand ; Clin Lab Invest. -)N*)Q5""/".

*). 'ntman E3. Decision ma%ing $ith cardiac

troponin tests. J Engl ; 3ed. 1##1N)65Q1#"/0#.

*6. amm C=. Cardiac biomar%ers for rapid

evaluation of chest pain. Circulation. 1##-N-#6Q-6*6/

*5.

**. Penttila , ou%%unen , alinen 3, et al.

3yoglobin, creating %inase 3 isoforms and creatine

%inase 3 mass in early diagnosis of myocardial

infarction in patients $ith acute chest pain. Clin

iochem. 1##1N)*Q56"/60.

*5. :rench ;, 8amanathan , te$art ;T, etal. '

score predicts failure of reperfusion after fibrinolytic

therapy for acute myocardial infarction. 'm eart ;.

1##)N-6*Q*#0/-#.

*". 'pple :, Huist E, Doyle P;, et al. Plasma th

percentile reference limits for cardiac troponin and

creatine %inase 3 mass for use $ith European


90/96

90

ociety of Cardiology+'merican College of Cardiology

consensus recommendations. Clin chem.

1##)N6Q-))-/)).

*0. 'pple :. Tissue specificity of cardiac troponin

I, cardiac troponin T and creatine %inase/3. Clin

Chim 'cta. -N106Q -*-/*6.

*.


91/96

91

51. 'pple :, 3ura%ami 33, ;esse 8L, et al. Jear/

besides $hole/blood cardiac troponin I assay for ris%

assessment of aptietns $ith acute coronary

syndromes. Clin Chem. 1##1N60Q-"06/05.

5). :reed 3 et al.


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92

5". 'llemann M, aufmann KP, 3eyer ;,


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93

Intervention for Chronic Total Occlusion. Monsei 3ed ;

1##5N6"Q50#/50".

"1. Par% C, im , Par% , Ihm , im D, Lee ;, et

al. Clinical, Electrocardiographic, and Procedural

Characteristics of Patients =ith Coronary Chronic

Total Occlusions. orean Circ ; 1##N)Q---/--*

"). oye ', van Domburg 8T, onnenschein ,

erruysP=. Percutaneous coronary intervention for

chronic total occlusionsQ the Thora!center e!perience

-1B1##1. Eur eart ; 1##*N15Q 15)#B15)5

"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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96

C$ (ee& Raise": Y / N

Car"iac ,am+ona"e: Y / N

#eri+roce"ura& "eath: Y / N

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