血管内超声引导下经远段分支正向夹层再入真腔技术在慢性完全闭塞病变中的应用

Application of intravascular ultrasound-guided antegrade dissection re-entry technique via distal branches in chronic total occlusions

摘要

分析血管内超声引导下经远段分支正向夹层再入真腔技术在冠状动脉慢性完全闭塞（CTO）的经皮冠状动脉介入治疗中的应用现状与进展。首先，阐述CTO临床治疗现状以及血管内超声在确认导丝内膜下位置、识别远端真腔、选择最佳再进入点及监控并发症中的关键作用。其次，汇总现有临床研究证据，分析该策略相较于传统非影像引导或近端入路正向夹层再进入真腔技术的潜在优势，包括复杂性CTO患者（包括合并心力衰竭、肾功能不全、反复支架内闭塞）的注意事项以及当远端分支与主干的夹角>70°或≤70°的手术策略。同时，讨论其对器械要求高、潜在增加对比剂用量与辐射暴露等局限性。最后，对该技术未来的优化方向（如与新技术结合）及应用前景进行展望，以期为临床实践提供循证参考。

Abstract

An analysis is performed on the current status and advances of intravascular ultrasound-guided antegrade dissection re-entryvia distal branches in percutaneous coronary intervention for chronic total occlusions (CTO). This study first elaborates on the clinical status of CTO and the crucial role of intravascular ultrasound in confirming the subintimal position of the guidewire, identifying the distal true lumen, determining the optimal re-entry point, and monitoring complications. Subsequently, it summarizes the existing clinical research evidence and analyzes the potential advantages of this strategy compared with traditional non-imaging-guided or proximal access antegrade dissection true lumen re-entry techniques, covering precautions for complex CTO patients (including those complicated with heart failure, renal dysfunction, or recurrent stent occlusion) and procedural strategies applicable when the distal branch-main vessel angulation is > 70° or ≤ 70°. Meanwhile, the limitations including the high requirements for equipments, potential increase in contrast agent usage, and radiation exposure are discussed. Finally, the future optimization directions (such as integration with new technologies) and application prospects of this technology are presented, aiming to provide evidence-based references for clinical practice.

关键词

慢性完全闭塞 / 血管内超声 / 正向夹层再入真腔 / 远段分支 / 预后

Key words

chronic total occlusion / intravascular ultrasound / antegrade dissection re-entry / distal branch / prognosis

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基金资助

国家自然科学基金(81974026)

湖南省科技厅项目(2024ZK4103)