冠状动脉慢性闭塞病变介入治疗综析

发布时间：2016-08-04 09:49

慢性完全性闭塞（Chronic Total Occlusion, CTO）作为冠状动脉慢性闭塞病变的一种，通常意义上闭塞时间会超过三个月。CTO病变目前接受皮冠状动脉介入术(Percutaneous Coronary Intervention, PCI)者少于8%，只占PCI全部病例的10%~20%【1,2】。尤其对于病变时间长或病变段较长的患者治疗，如何成功地开通血管并在长期内保持较好的效果存在很多问题。PCI在近30年内随着介入制造工艺水平和手术器械涉及的提高、一些辅助设备的出现完善和相关药物治疗的进展取得了大踏步的前进。手术成功率的提高，使更多的患者开始接受这种曾经相对危险的治疗方法，但CTO病变治疗仍然是心内科介入医生面临的挑战之一。

1. CTO的定义、分类及病理

学术界关于CTO的定义有很多说法，，至今尚未统一。在本研究中，根据ACC的最新定义，将CTO特指为闭塞时间超过三个月的病变【3】。同时，根据是否有前向血流的存在，进一步将慢性完全闭塞病变分为慢性完全性闭塞（前向血流TIMI 0级）和慢性功能性闭塞（前向血流TIMI 1级）【4】。作为动脉粥样硬化病变发展为严重狭窄病变的最终阶段，CTO病变在静息状态下的心肌需氧量相对比较少，如果有侧枝循环的建立，那么患者可以维持心肌存货，但是如果体力活动增加或者情绪有强烈波动则会因为不能增加供氧而出现心绞痛等现象，使患者的生活水平下降，生命也受到危险。因此，通过指引导丝通过新生微通道可以提高运动耐量从而有效改善患者的状况。

2. CTO的组织病理学、临床表现及临床意义
2.1 组织病理学
2.2 临床表现
2.3 临床意义
3. CTO病变血运重建的理论基础
3.1 闭塞部位存在存活心肌
3.2 抑制左室重构
4. CTO再灌注介入治疗
4.1 再灌注策略
4.2 器械选择
4.3 影响手术成功的因素
5. CTO病变治疗中一些新技术和器械的研究进展与展望
5.1 Frontrunner导管
5.2 内膜下寻踪及再入STAR技术 
5.3 平行指引导丝技术和跷板指引导丝技术
5.4 逆向导引钢丝对吻技术
5.5 CART
5.6 导丝捕获技术
5.7 超声治疗Crosser系统
5.8 斑块消化
5.9 PCI联合干细胞移植
5.10 准分子激光导管
5.11 磁导航导操作系统
6．    降低CTO患者术后再狭窄率的研究进展以及患者的预后
6.1 CTO病变治疗中支架应用
6.2药物洗脱支架治疗CTO进展
6.3个人介入技术

综上所述，在冠脉介入治疗中，CTO始终是最大的挑战，虽然还有很多的缺陷和不足，但是随着器械的研究改进、医者的经验增加，手术成功率可以得到一步步的提高。这些临床经验的增加和科学研究的进步将为患者的长远受益将有极大帮助，医者对病变本身也会有更深刻的认识。
 

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