Aspectos clínicos e técnicos atuais das abordagens anterógrada e retrógrada da intervenção coronária percutânea para a oclusão crônica

Abstract

Percutaneous coronary intervention for the treatment of chronic total occlusions (CTO) has experienced remarkable progress in recent years. Firstly, appropriate angiographic evaluation is essential for providing clear imaging of the coronary arteries and their branches. Observed in detail are the pattern, length, and direction of the CTO; the condition of the side branches; the pattern of vessels distal to the occluded segment; and the extent of calcification. Each of the collateral pathways is evaluated very carefully, and the course from the origin to the termination in the distal part of the occluded vessel is identified. Secondly, selecting adequate devices for treatment is very important. The antegrade approach, using conventional guidewire and microcatheters, is always the first choice. Progressively more rigid guidewires may be required, as well as special devices and techniques. The retrograde approach is indicated when the antegrade approach fails in cases where the entry point of the occlusion is not identified or in patients with extremely calcified lesions. The optimal collateral access for this technique is a wide and straight septal branch, but such an ideal vessel is rarely found. The retrograde approach is explained in detail, and suggestions are provided to overcome anticipated obstacles during the procedure. The experience gained at this service, along with the different strategies and the use of adequate devices, has led to a current procedure success rate of over 90% in cases of CTO.

Impacto clínico da isquemia e viabilidade miocárdicas após tratamento de oclusão coronária crônica no segmento proximal da artéria descendente anterior

“…[4][5][6] In the treatment of the left anterior descending artery proximal segment, it is notable the best clinical outcomes of patients treated with DES, when compared with those treated with BMS, 7 with a similar clinical outcome to that of patients undergoing coronary artery bypass graft (CABG) surgery using graft from the left internal mammary artery to the left anterior descending artery. 8 Particularly in patients with chronic coronary occlusion, 9,10 and specifically in the proximal segment of the left anterior descending artery, 11 the beneficial effect of DES on clinical outcomes in the long-term when compared to patients receiving BMS is indisputable; DES is recommended by Brazilian 12 and international guidelines. 13,14 Currently, percutaneous revascularization is an excellent option in the management of chronic coronary occlusion, but proper selection of patients and a careful assessment of the anatomical lesion aspects, the availability of devices dedicated to the management of occlusions, and the availability of DES are paramount.…”