脑血管闭塞性病变的再通治疗 - 安全性和疗效的术前评估 张勇 青岛大学医学院附属医院

What is CTO Defination:  Lesion with TIMI 0-1 Flow  Duration of >3 months estimated from symptom onset Technical Success:  Restoration of TIMI 3 flow  Residual stenosis of < 20-50%

Why should we open a total occlusion lesion  Although CTO is classic stable lesion  But  Collaterals maybe not sufficient to maintain the brain function  CTO determines the outcome of a future CI

Potential harm of recanalization  Embolization  Hyperfusion syndrome  Dissection  Guidewire perforation and rupture

Rationale for CTO recanalization  Evaluations  Patient selection  Techniques  We must remind ourselves at any time that the brain is the most unforgiving organ.

Evaluation  neuroimaging  Brain matter ： CT/MR  Brain perfusion ： CTP/MRP/PET/SPECT  The vasculature of the brain  MRA  CTA  DSA We must evaluate the benefits and risks of the procedure and then make the decision.

Perfusion-diffusion (PWI-DWI) mismatch  mismatch=PWIvol-DWIvol/DWIvol×100>20%

Patient selection --Can we recanalize CTO safely  Favorite:  Microchannels  Straight vessel  Short lesion  Without large infarct

Micro-channels : Pathological Rationale for CTO Treatment

Techniques From Standards Wires and techniques to…  Specialized wires  Hydrophilic (Whisper, PT2, Pilot, Terumo, Shinobi)  Tapered tip (Cross-IT XT family)  Enhanced force and torque (Miracle, Confianza, Persuader and others)  Specialized Techniques  Controlled drill and penetration and sliding  Parallel wire technique  …… Most importantly, you must be patient!

Case 1  62 yrs male  Vertigo for 3 months  PE ： almost normal  CT ： no infarts  DSA

治疗

结果

临床结局  头晕消失，恢复工作能力。  随访 1.5 年

Case 2  Male ， 74yrs ， aphasia and left hemiparasis for 10 months  Cranial MR at onset

颅脑 DSA

治疗设计  开通后小球囊成形，一月后内膜修复后二 次支架成形  假想：  降低高灌注风险  避免过多支架使用  降低再狭窄

第一次治疗

第二次手术

手术前后的比较

临床结果  1 月后随访，语言及右侧运动功能明显改善。

Case 3  male ， 56 yrs at onset (2005)  Smoking for more than 20 yrs.  Aphasia and left hemiparasis for 8 hrs ( July 4 th, 2005)  PE ： incomplete aphasia, muscle power grade 2 on the right side.

CTA RVA and RICA stenting well LICA sub-occlusion

Treatment

临床结局  语言功能明显好转

CASE 4  Male, 68  Infarcts in brain stem and cerebellum  Ataxia

CASE 4

临床结局  头晕明显减轻，吞咽困难消失  构音障碍减轻

Our experiences  14 cases, 2 of vertibrobasilar artery, 12 of carotid artery  12 succeed and 2 (both of carotid artery) failed without any consequence  The occlusion extended from the origin to the cavernous of carotid artery in both failed cases.  We cannot make sure where is the true lumen in the tortous part of the vessel  Both patients had EC-IC bypass successfully later.  We must concede that we lack a randomized controlled trial to compare PCI in CTOs versus medical management.

When to stop and when to say no  When to stop…  > 30 minutes Cross time  > 300 cc contrast  > 90 minutes total procedure time  When to say no…  Long Tortuous Gap  Severe Calcification  Poor Distal Vessel Visualization  No prospect for Retrograde

Common Misperceptions and CTO Complications  The vessel’s already occluded, it can’t get any worse….  There’s no evidence of contrast extravasation, so we didn’t perforate….or  It’s just a wire ‘exit’, not a perforation….  If the wire enters a dissection or won’t advance, you’ll never get through, and it’s time to quit….  If you don’t get through it on the first try, you never will

Summary  Treatment of CTOs has introduced new benefits, new dilemmas  Historical predictors of procedural success are ‘historic’  Patient identification with non-invasive imaging  Strut fracture and LSM may be more common; clinical implications uncertain  Despite more advanced strategies and technologies, there is little systematic evidence that procedural outcomes have changed for the better or worse  New techniques, new complications  Need CTO-specific clinical trials that better inform procedural outcomes