Author name:
حسن عبد الامير الداغر
Supervisor name:
حسن النجار
Abstract:
I want to evaluate the influence of diabetes mellitus (DM) on the results of percutaneous coronary intervention (PCI) of patents with chronic total occlusion (CTO) and to compare that with the results in non diabetic patients.Patients and Methods We had prospectively studied 150 consecutive cases of chronic total occlusion (CTO) who had percutaneous coronary intervention (PCI) at Iraqi center for heart diseases - Baghdad/Iraq for the period January - December 2012. All patients were symptomatic. We recorded patients baseline characteristics, which coronary artery involved, the segment/s involved, and whether the patient diabetic or not and impact of these parameters on the hospital outcome of the intervention. We also looked at influence of hypertension (HTN), hyperlipidemia (HLP), smoking (SM), and positive family history (PFH) for ischemic heart diseases, on the outcome of the intervention as well.Results : Success of revascularization of chronic total occlusion by percutaneous coronary intervention was similar in both sexes (male 69.4% female 72.4%). Intervention was successful in 40 out of 55 patients with diabetes mellitus (72.7%) which was identical to those without diabetes mellitus (66 patients out of 95 patients (69.47%).The success in diabetic and non diabetic groups in the absence of other risk factors was 64.2 % and 62% while in the presence of these risk factors it was 73.1% and 71.2 % respectively.In 11 out of the15 patients with diabetes failed intervention was attributed to inability to pass the wire (73.3 %.) compared to 23 out of the 29 nondiabetic patients (79.3%). While failure to pass the balloon was identical in both groups (13.3% compared 13.7 and failure to pass a stent while it was not reported compared to 3.4% in both diabetic and non - diabetic patients respectively. As far as failure of procedure, concerning passing the guide wire into a false lumen and creation of perforation had occurred in 13.2 % of the diabetic group compared to 3.4% in the nondiabetic group.Successful revascularization has led to a prompt relieve of symptoms; angina and improved exercise tolerance as well as enhanced left ventricular function equally in both groups.Conclusion : Regarding CTO - PCI, there was no much difference between success in diabetic and non diabetic patients. The beneficial effect of successful recanalization of CTO on overall survival free of major adverse events was clearly apparent to be irrespective of diabetic status. Presence of additional risk factors other than diabetes mellitus has no additional burden on the results of such interventions.CTO - PCI should be done in all patients with prognosticaly significant ischemia or heart failure with significant viability.Introduction A CTO was defined as a lesion exhibiting Thrombolysis in Myocardial Infarction flow grade 0 - 1 of a native coronary artery. Technical success was defined as the ability to cross the occluded segment with both a wire and balloon and successfully open the artery with a <40% residual stenosis in all views. Procedural success was defined as a technical success with no in - hospital major adverse cardiac event (MACE). A CTO success was defined as a technical success. A MACE was defined as the occurrence of death, Q - wave MI or urgent revascularization. Urgent revascularization was classified by operators caring for patients and required repeat PCI of target vessel during the same admission or coronary artery bypass graft surgery (CABG) including bypass of the target vessel. Repeat percutaneous transluminal coronary angioplasty (PTCA) was defined as a subsequent procedure in the occluded vessel. (1)Dates highlight a striking survival advantage among patients with a successfully opened occluded artery versus those whose procedure was unsuccessful. Work supports the concept of a time - independent benefit of reperfusion. Results elucidate the importance of revascularization of a CTO, and they represent long - term follow - up on the largest reported series of treated chronic coronary occlusions. Although success rates have continued to improve over time, attempted revascularization does not come without complications. The MACE rates, although constant, were found to be 3.8% overall. With proper training and by carefully selecting the lesions attempted, aggressive intervention of a CTO is justified. (1)CTOs are a continuum of atherosclerotic progression leading to plaque rupture with thrombus formation. Over time, this thrombus tissue will be converted to fibrous tissue composed mainly of collagen and, in the later phase, calcium. Histopathologically, CTOs are characterized by inflammation, neovascularization, and the extent of calcification. The plaque that forms a CTO is also categorized as soft, hard, or mixed. Soft plaque is primarily composed of cholesterol - laden cells and foam cells that are generally more amenable to wire passage. The hard plaques are composed of dense, fibrous tissue with fibrocalcific regions that are more resistant to wire passage. (2)PCI of chronic total occlusion represents 10% - 20% of all angioplasty procedures and poses a management, dilemma for the interventional cardiologist (3).A CTO was defined as obstruction of a native coronary artery with no luminal continuity and Thrombolysis in Myocardial Infarction (TIMI) flow grade 0 or 1. The duration of occlusion had to be more than 3 months, estimated from clinical events such as myocardial infarction, sudden onset or worsening of symptoms or proven by previous angiography. Technical success was defined as restoration of TIMI flow grade 2 or 3 with residual stenosis <15 %.( 3). Patients with diabetes mellitus (DM) constitute patient group with a high prevalence of multivessel disease (MVD) and high mortality after ST elevation myocardial infarction (STEMI). Approximately 35 - 45% of non - diabetic STEMI patients have MVD compared with 60 - 70% of patients with DM. The higher mortality of STEMI patients with DM has been suggested to be at least partly due to the greater extent of coronary artery disease. Recently, the presence of a chronic total occlusion (CTO) in a non - infarct - related artery (non - IRA) and not MVD alone was reported to be an independent predictor of mortality after STEMI. Given the greater extent of coronary artery disease in diabetic patients with STEMI, it was hypothesized that the prevalence of a CTO in a non - IRA would be higher in this high - risk subgroup. Moreover, the prognostic impact of a CTO in a non - IRA in diabetic patients with STEMI is currently unknown. (4)Two retrospective studies from the 1990s suggested that the prevalence of CTO in patients with coronary artery disease (CAD) on coronary angiograms ranged from 33% to 52 %.( 5)The true prevalence of CTO in the general population is unknown as a certain proportion of patients with CTO are asymptomatic or minimally symptomatic. (5)Successful CTO PCI is associated with improved survival out to 5 years. Adoption of techniques and technologies to improve procedural success may have an impact on prognosis. (6)Pre - selected variables CTO - PCI for were age, gender, diabetes mellitus, hypertension, and hypercholesterolaemia, presence of multivessel disease, impaired left ventricular function, prior AMI, prior PCI, and prior CABG, use of a glycoprotein IIb/IIIa inhibitor, target vessel, successful procedure, and use of a stent. (7)Coronary chronic total occlusions (CTOs) are commonly encountered complex lesions identified in 15% of all patients referred for coronary angiography. Chronic total occlusion remains the most powerful predictor of referral for coronary bypass surgery. The benefits of CTO percutaneous coronary intervention (PCI) include symptom relief, improved left ventricular function, and potentially a survival advantage associated with success when compared with failed CTO - PCI.(8)Recent advances in CTO - PCI techniques that have broadened PCI indications and improved success rates can be categorized into ante grade and retrograde techniques. (8)No consensus exists for selecting an initial approach to a CTO (ante grade vs. retrograde). The most common reason to use retrograde techniques among experienced CTO operators is failure to succeed using the ante grade approach. If failure with the ante grade approach is imminent and fluoroscopy time is <30 min, the change can be made ad hoc. In the event that greater time has been used, the patient should be brought back for a staged attempt at least 48 h after the first attempt. Certain subsets of patients, including those with long lesions (>20 mm), ostial occlusions, extreme tortuosity, severe calcification, and small or poorly visualized distal vessels may also be selected for a primary retrograde approach. (8)Technology continues to grow in the field of interventional cardiology. The evolution of newer wires, stents, support catheters, and forward - looking devices, such as the Safe - Cross, will continue to improve success rates in treating CTOs. Success, however, will improve only in the appropriately selected patient. The question of routine intervention for CTOs was effectively answered by the Occluded Artery Trial (OAT) investigators, who demonstrated no reduction in death, reinfarction, or heart failure with routine intervention to persistently occluded arteries after myocardial infarction. The ideal patient is one who has persistent angina with suitable lesion anatomy consisting of a tapered occlusion, angulation <45°, a single lesion, and lesion length <15 mm. The appropriately selected patient can now look forward to increased successful recanalization and safety during treatment of CTOs using the Safe - Cross System, which is unique in its ability to assess the intraluminal tissue in real time. (9)Among all patients who undergo coronary arteriography, CTO is present in at least 30% of cases. Coronary CTO remains one of the most challenging lesion subsets in interventional cardiology, even with the development of medical devices and operator expertise, although the long term outcome of PCI for CTO is currently unknown. There is a benefit of cardiac magnetic resonance (CMR), a safe, noninvasive technology, for the follow - up and assessment of the efficacy of a complex PCI procedure like CTO. (10)Methods : I had studied 150 cases of CTO who had undergone PCI at Iraqi center for heart diseases regarding the base line characteristics. Then I classified the patients according to arterial and then segmental involvement. So also I verified the causes of failure and number of attempts of PCI in both diabetic and non diabetic groups. After that I studied the success of CTO - PCI in both diabetic and non diabetic patients when diabetes was the only risk factor and also the success in the presence of other risk factors for ischemic heart diseases in both groups.Then I studied both groups according to age groups, sex with relation to success and failure.Results : Chi - square test was used to analyze the statistical association between the various selected variables. Statistical significance was accepted for P ≤ 0.05 (significant). and P > 0.05 (insignificant).
