Occlusion - sharply arising from vessels. The cause is the development of pathological processes, clogging by thrombus, traumatic factors. Localization is distinguished different types occlusion, for example, it can affect the arteries of the heart. It is supplied with blood two main vessels - left and right coronary arteries.

Because of their obstruction, the heart does not receive the desired amount of oxygen and nutrients, which leads to serious disorders. Often there is a few minutes, sometimes hours, so you need to know the causes and symptoms of occlusion.

The reasons

The processes that occur during the formation of coronary occlusion are largely determined by morphology. Most often, chronic occlusion begins to form since the formation of an intra-road fresh blood cloth. It is he who fills the clearance - after the fibrous capsule of an unstable atherosclerotic plaque is broken at.

The formation of thrombus occurs in two directions from the plaques. The length of occlusion is determined by the location of large side branches with respect to occlusive plaques.

There are several stages of formation of the structures of chronic occlusion of heartfood.

1. The first stage is durable to two weeks. There is a sharp inflammatory response to acute thrombosis, the breaking of an unstable plaque. The vascular microchannels are formed. There is infiltration of thrombotic material with inflammatory cells and myofibroblasts. The arterial list of fresh blood cloth is platelets and red blood cells in fibrin frame. Almost immediately they begin infiltration of inflammatory cells. The endothelium cells are also migrated in the fibrin grid and participate in the formation of thin structures, microscopic tubules inside the thrombus, which begins to organize. At this stage, structured tubular channels in thrombotic occlusion are not formed.
2. The duration of the next, intermediate stage is 6-12 weeks. There is a negative remodeling of arterial lumen, that is, the cross-sectional area decreases by more than 70%. The elastic membrane is breaking. In the thickness of the occlusion, microscopic tubules are formed. Thrombotic material continues to form. Other pathological processes occur. Active inflammation develops, the number of neutrophils, monocytes, macrophages increases. The formation of a proximal capsule occlusion begins, which includes almost only tight collagen.
3. The stage of maturity lasts from 12 weeks. In occlusion, soft tissues are almost completely displaced. There is a decrease in the number and total area of \u200b\u200bthe tubules compared to the previous period, but after 24 weeks it does not change.

The formation of atherosclerosis plaques on the coronary artery

Why are such processes begin to develop? Of course, a healthy person with good vessels above described does not occur. In order for the vessels of steel sharply impassable or occlusion gained chronic character, on the heart, coronary arteries should act some factors. Indeed, several reasons prevent normal blood flow.

1. Embolism. Inside the arteries and veins can form embols or clots. This is the most common cause of the obstruction of the arteries. There are several types of this state. The air embolism is a state when a bubble with air penetrates into the vessels. This often happens with serious damage to the respiratory organs or incorrectly performed injection. There is also, which may have a traumatic character, or arise as a result of deep metabolic disorders. When fine fat particles accumulate in the blood, they are capable of connecting to the fat thrombus, which cause occlusion. Arterial embolism is a condition in which vascular lumen is blocked by moving blood closures. Usually they are formed in the valve apparatus of the heart. This occurs at various heartfill pathologies. This is a very frequent cause of occlusion of the arteries in the heart.
2. . It develops in the event that a thrombus appears and begins to grow. It is attached to the venous or arterial wall. Thrombosis is often developing during atherosclerosis.
3. Vascular aneurysm. So refer to the pathology of the arteries or veins walls. There is their expansion or protrusion.
4. Injuries. Fabrics whose damage occurred by external reasons, begin to put pressure on the vessels, which is disturbed by blood flow. This causes the development of thrombosis or aneurysm, after which occlusion occurs.

It is important to remember that the emergence of some of these reasons is due to lifestyle. Atherosclerosis, the blood clots are formed due to the fact that a person abuses alcohol, smokes, it doesn't eat, moves little, is experiencing frequent stress. All this very badly affects both the whole body and on his vessels.

If you start to start with young age so incorrectly, there may be serious problems. Unfortunately, they are observed even in those who once led the wrong way of life, of course, the degree of disease is not so acute. If you exclude negative factors from your life as early as possible, the probability of occlusion will be much smaller.

Symptoms

The manifestation of symptoms is directly dependent on the work of the heart, because his defeat goes. Since as a result of occlusion it ceases to receive power and oxygen, it cannot remain unnoticed for humans. He suffers from the work of the heart, and it is manifested in the soreness of this area. The pain can be very strong. Man begins to experience difficulties with breathing. As a result of oxygen starvation of the heart, flies may appear in the eyes.

The person weakens sharply. He can grab the right or left hand over the heart area. As a result, this situation often leads to loss of consciousness. It should be borne in mind that the pain can give in hand, shoulder. Signs are very pronounced. In any case, it is necessary to provide first medical care.

Treatment

It is necessary to remove pain, spasm. To do this, give an anesthetic. Well, if there is an opportunity to make the injection of papaverine. If a person has a heart cure with him, you need to give it in the right dose.

The main thing is not to panic. If there is stuffy and hot in the room, you need to open the window, to ventilate it. Remove clothes that may make breathing. Do not do without a call to ambulance! It should be called immediately as soon as a person has become bad.

After providing assistance with medical specialists, the victims will be taken to the hospital. There is a patient examination. In any medical institution an ECG is available. When it is deciphered, then take into account the depth and height of the teeth, the deviation of the isoline and other signs.

Also, the ultrasound of the heart and blood vessels are carried out, arteries. This study helps to identify the effects of occlusion, blood flow disorders. It is useful to carry out the coronary of the blood vessels with the introduction of a contrast agent.

Treatment of acute occlusion manifestations is a difficult matter. His success depends on the timely identification of the first signs of the defeat of the coronary arteries. Basically, you have to resort to surgical intervention in order to clear the internal cavities of the arteries, delete the affected areas. Conduct arterial.

In order not to bring the body before, it is necessary to support cardiovascular system Normally. To do this, a number of preventive measures should be followed:

1. Need to monitor the level arterial pressure. It is best to refer to use strong tea, coffee, salt and sharp food.
2. It is important to eat right. This means that you need to reduce the consumption of fatty. After forty years, it is necessary to pass tests to the level of cholesterol at least once every six months. Every day, natural products in which many vitamins and the necessary trace elements should be used.
3. It is necessary to get rid of OT. excess weightSince it has a serious load on the heart and vessels.
4. It should be refused OT. harmful habits. This applies to smoking and alcoholic beverages. In medical practice there were cases when a sharp spasmatic occlusion occurred, which was caused by alcohol or nicotine.
5. It is necessary to avoid stress and mental shocks.

Thanks to such simple measures, you can protect yourself from hazardous consequences. It is important to understand that occlusion represents real threat For human health and life. You need to prevent it or provide first medical care!

The main cause of death In Western countries, ischemic heart disease as a result of the insufficiency of the coronary blood circulation. In the US, 35% of the population dies for this reason. Sometimes death occurs suddenly, as a result of acute coronary artery thrombosis or heart fibrillation. In other cases, the weakness of the heart muscle develops gradually for weeks and even years. This chapter discusses the development of acute coronary ischemia as a result of acute coronary occlusion and myocardial infarction.

Atherosclerosis It is the cause of ischemic heart disease. Most frequent cause Reducing the coronary blood flow is atherosclerosis. The development of an atherosclerotic process is a specific violation of lipid metabolism. The essence of this process is as follows.

In people with genetic predisposition to, as well as people who consume a large amount of cholesterol with food and leading a low-wear lifestyle, excess cholesterol is gradually postponed in arteries under the endothelial layer. Gradually, these deposits germinate with fibrous cloth and are often calcined. As a result, atherosclerotic plaques are formed, which protrude into the lumen of the vessel and lead to a complete or partial overlap of blood flow. A typical location of atherosclerotic plaques is the first few centimeters of large coronary arteries.

Acute coronary occlusion

Acute coronary occlusion (the blockage of the vessel) is more often developing in people with atherosclerosis of coronary arteries and almost never - in people with normal coronary blood circulation. Acute occlusion can be caused by one of the following reasons. 1. Atherosclerotic plaque leads to local coagulation of blood and the formation of a thrombus, which overlaps the clearance of the arteries. Thromb arises if an atherosclerotic plaque damages endothelium and comes into direct contact with flowing blood.

Because Blya It has an uneven surface, the fibrin surface is adhesion to the surface of the plaque, the fibrin is postponed, a red thrombus is formed, which continues to grow until the vessel is completely blocked. Often, the thrombus is separated from the atherosclerotic plaques and with a blood current falls into the peripheral branch of the coronary artery, blocking the bloodstream in this area. The thrombus, which clog the vessel, falling into it with blood, is called embolmi. 2. Many clinicians believe that the local spasm of the coronary artery can also cause circulatory disruption. The cause of the spasm can be direct irritation of the smooth muscle wall artery wall by the edges of the atherosclerotic plaque or the local reflex vesseloring effect. Spasm artery leads to secondary thrombosis.

Vital importance collateral blood circulation in the heart. The severity of damage to the heart muscle both during the slow development of the atherosclerotic process and during the sudden occlusion of the coronary arteries to a large extent depends on the state of the collateral blood circulation of the heart. It is important and the already existing collateral network, and collaterals, which are opened in the first minutes of occlusion.

In a healthy heart, there is practically no collatomera Between large coronary arteries, however there are many collateral anastomoses between small arteries with a diameter of 20 to 250 microns.

With sudden occlusion one of basic coronary arteries Small anastomoses begin to expand after a few seconds. However, blood flow through small collateral vessels is usually 2 times less than it is required for the survival of cardiac cells.

For the next 8-24 h The diameter of collateral anastomoses does not significantly increase. Then collateral blood flow begins to grow. On the second or third day, its intensity increases 2 times, and by the end of the first month, the coronary blood flow reaches a normal level. Thanks to the development of collateral vessels, many patients are almost completely recovered after transferred coronary occlusion, unless the zone of myocardium damage was too large.

If a atherosclerotic narrowing of coronary arteries Progresses slowly, for many years, collateral blood circulation develops as an atherosclerotic lesion becomes harder. Therefore, such patients never happen acute violations Heart activities. However, collateral blood flow cannot compensate for increasing development of the sclerotic process, especially since atherosclerosis is often striking and collateral vessels themselves. If this happens, the performance of the heart is dramatically limited, it turns out to be unable to pump the required blood volume even at rest. This is the most common cause of heart failure in a large number of older people.

Educational video of blood supply to the heart (anatomy of arteries and veins)

During problems with watching download video from page

The blockage of the coronary artery, or atherosclerosis of the coronary artery, occurs when blood vessels are scored or clogged, which provide blood with blood. This type of blockage significantly increases the risk of a heart attack, one of the leading causes of death, both in men and women. Many cases of coronary artery blockage are the result of ischemic heart disease. Signs of coronary heart disease include pain or sense of compresses in the chest, cold sweat and difficulty breathing. People encountered with any of these symptoms should immediately contact the doctor for the diagnosis and treatment of treatment. Those who are included in the risk group of coronary heart disease, should be taken care of making changes to lifestyle and diet to reduce the risk of coronary artery blockage.

Coronary artery - These are blood vessels that provide blood heart. Three large coronary artery are distinguished: the left front descending artery, the envelope of the artery and the right coronary artery. Each artery delivers blood to various parts of the heart. The left front artery delivers the blood to the front of the heart, envelope - to the rear, and the right coronary artery to the bottom. If any of these arteries turns out to be blocked, serious complications may arise, including severe breast pain, heart attack And even death.

As a person ages, burning sediments can form on the walls of the coronary arteries.

Some people have these sediments are quite significant and contribute to the blockage of the arteries. They become the reason that waste and other cells are sticking to the walls of the arteries. Over time, these sediments can harden. Harding deposits, called cholesterol plaques, can interfere with the blood supply to the heart, causing partial blockage of the coronary artery. If the solid sheath of plaques is damaged or cracks, the body begins to close the crack. For this, it uses platelets that are glued to the crack and to each other. This forms a thrombus.

Thrombus can block the coronary artery completely. Without proper blood supply, the heart turns out of oxygen.

In the absence of sufficient amount of oxygen, the heart is dangerous. In the case of partial blockage of the coronary artery, a person can feel a feeling of shy or pain in the chest when performing hard work or the occurrence of a stressful situation. This is because the blood is poorly passed through the arteries and does not provide a heart with a sufficient amount of oxygen. If there is a complete blockage of the coronary artery, the bloodstream is blocked at all, which can lead to a heart attack.

To prevent the blockage of the coronary artery, it is necessary to adhere to the lifestyle that reduces the risk of its development. The main risk factor is the high level of cholesterol, so avoiding this disease helps the use of food having a low cholesterol content. Procedures such as balloon angioplasty can be used to eliminate fatty sediments. Also doctors can assign to maintain the risk of blockage of the coronary artery at a low reception medicinal preparations and recommend classes with physical activity and making other changes in lifestyle.

Occlusion vessels - This is the restriction of vessels, which is due to the fact that on one of the sections, the vascular lumen is blocked. The occlusion of the vessel is a dangerous state, since it leads to the development of ischemia organs, causing heart attacks and strokes. Acute occlusion carries a threat, because in a matter of hours it leads to necrotic processes in the tissues.

The reasons

Occlusions of vessels are associated with the state of vascular failure. Occlusive process occurs:

• as a result of injuries, if the artery is shifted.
• due to the fact that the clever cloved by thrombus or embolomes.

The formation of thrombus contributes to a chronic disease - atherosclerosis of vessels. Ground and increasing in diameter, atheromatous plaques interfere with normal blood flow. Atherosclerotic plaque leads to clotting blood and thrombus formation. Occlusions cause separated fragments of plaques that are freely moving along the vascular bed. In addition, as a result of atherosclerosis, the walls of the vessels lose their elasticity, become thinner and smell under blood pressure, which becomes the cause of the formation of aneurysm. On the vessel plot, where the expansion appeared, with a high probability of thrombosis or embolism.

Symptoms

Symptoms of occlusion depend on the arterial pool there was a blockage of the vessel.

Occlusion of blood vessels

The hazardous state is the acute occlusion of coronary arteries, which supply the heart muscle with blood. This occurs as a result of atherosclerosis of coronary arteries and ischemic heart disease. If, in the chronic course of the disease, the person faces angina, the sharp form is fraught with infarction and even the death of the patient. Typical signs of the occlusion of the blood vessels are pain behind the sternum, which continue more than 10 minutes and do not pass at rest or after taking nitroglycerin. In this case, the concept of acute coronary syndrome is used: the patient with such symptoms should be immediately hospitalized.

The danger lies in the fact that the symptoms of ischemic illness initially ignores or simply does not feel without undertaking any measures. For occlusion of vessels, suddenness and surprise is characteristic, so at the first signs of developing ischemic illness immediately consult a doctor.

Occlusion peripheral vessels of vessels

The occlusion of vessels is subject to large arteries of the limbs, more often - the lower. Occlusion are an unpleasant consequence of diseases of the foot vessels. At the same time, the threat of an acute occlusal process in this area is dangerous by the development of tissue necrosis, which leads to amputation of the affected limb. Characteristic signs of burgong burghitis, atherosclerosis of foot vessels and other common pathologies are:

• pain in the legs that do not pass at rest;
• the pallor of the skin of the limbs;
• coldness in the legs;
• feeling of tingling, numbness in the limb;
• violation of motor limb functions.

When these symptoms appear, it is recommended to immediately conduct an examination and treatment of limb vessels: the slightest delay can turn into the development of gangrenes. On the early stages Development of the disease Treatment of oblique atherosclerosis of the lower extremities and other pathologies of sclerotic origin is carried out by conservative methods, while in a launched form to deal with the disease difficult.

Occlusional processes arise in kidney arteries - as a result, renovascular hypertension is developing, kidney dysfunction. Aorta is also exposed, since this is the largest vessel. About the consequences of atherosclerosis aorta read by clicking on the link.

Occlusion of blood vessels supplying brain

Occlusional processes in the arteries that feed the brain, hazardous consequences. Violation of cerebral blood supply is fraught with the development of stroke or coronary infarction of the brain, and this often ends with the death of a patient, para-galvanizing or dementia. The common cause of this is the occlusion of the carotid arteries. It is accompanied by loss of consciousness, nausea and vomiting, disorders of coordination, speech and vision, weakness and numbness of the limbs. Transient (cerebral) ischemic attacks are becoming precursor strokes, which we told in detail earlier.

Treatment

Most often, the only way to eliminate occlusion and resume blood supply - operational intervention. With complete blockage, it is necessary to perform the shunting of the arteries - an open operation to replace the affected area of \u200b\u200bthe vessel with an artificial prosthesis.

Chronic total occlusion coronary arteries: morphology, pathophysiology, technique of recanalysis

A.S. Tereshchenko, V.M. Mironov, E.V. Merkulov, A.N. Samko FGBU RKNPK MZ RF, Moscow

Abst

Expressive coronary intervention (CCV) in chronic occlusions of coronary arteries (CHOK) is a rapidly developing area of \u200b\u200binterventional cardiology. Recanabilization of coronary arteries is technically complex intervention. The most common cause of the unsuccessful Channelization of the COC is the impossibility of conducting an intrakoronary conductor through proximal and distal occlusion tires. Per last yearsFor understanding the morphology and pathophysiology of CHOC, studies have been implemented on the basis of which specialized tools and techniques for the recanalization of CHOK were developed and implemented. Also in this article, on the basis of clinical studies, the most effective stents are described with a low amount of restenosis.

Keywords: chronic occlusion coronary arteries, ischemic heart disease, percutaneous coronary intervention, recanalization.

Chronic Total Occlusions of Coronary Arteries: Morphology, Pathophysiology, Technique of Recanalization

A.S. Tereshchenko, v.m. Mironov, E.V Merkulov, A.N. SAMKO RUSSIAN CARDIOLOGY RESEARCH COMPLEX, MOSCOW

Percutaneous Coronary Intervention (PCI) for Chronic Total Occlusions of Coronary Arteries (CTO) Is a Rapidly Evolving Field of Interventional Cardiology. Recanali% ATion of the Coronary Arteries Is a Technically Difficult Intervention. The Most Common Cause of Unsuccessful Recanali% Action of a Cto Is Failure to Cross Intracoronary Wire The Proximal and Distal Caps of A CTO. Over The Pastfew Years In Order to Understand The Morphology andpathophysiology CTO's The Investigations Which Have Been Developed Andput Into Practice A Specialized Tool and Techniques for Recanali% Ation of the Cto. In This Article, Based On Clinical Studies Overview of the Most Effective Stents in Cto, with Low Restenosis Rate.

Key Words: Percutaneous Coronary Intervention, Coronary Heart Disease, Chronic Total Occlusions, Recanali% Ation.

Chronic occlusion of coronary arteries (CHOK) is the absence of antegrade blood flow along the coronary artery (blood flow T1M1 0) for more than 3 months. CHOK usually detect when conducting coronary angiography (kA). In the register, which includes 6,000 patients, with a significant damage to the coronary channel, in 52% of patients was detected at least one COC. The main obstacle to achieving successful recanalization is the impossibility of carrying an intrakoronary conductor for the place of occlusion. The unsuccessful recanalization of the coronary artery affects the choice of further patient treatment tactics. According to international data in patients with a detected in Calciation and with unsuccessful reccripts, the operation of coronary shunting or optimal drug therapy is possible.

Successful index reservation improves the forecast and quality of patient's life. After successful recanalization, angina attacks do not recur, the left ventricle emission fraction is improved and the need for execution is reduced.

coronary shunt operations. The data of large registers confirm the fact that the successful reanalysis of the CHOK improves a long-term forecast, compared with the unsuccessful coronary angioplasty of chronic occlusion. When implanting the olome-metal stents (HMS), the restenosis is one of the frequent complications associated with the reservation of the CHOK.

Nowadays, in the arsenal, endovascular surgeons have drugs with medicinal coating, which showed their effectiveness when stenting the CHOK, due to the low frequency of restenosis (2-11%) and repeated occlusion (0-4%), which has positively affected the long-term forecast of these patients.

Predictors of unsuccessful renovalization of CHOK.

Back in 1995, Rita J.A. et al. In its article on the recanalization of CHOC, several angiographic predictors of the unsuccessful recanalization of chronic occlusion were noted.

To such predictors, the authors attributed: extended occlusion; The presence of pronounced calcinosis in the area of \u200b\u200bocclusion, the presence of "bridges" collaterals (collaterals between the proximal and distal partitions of the occlusive artery), a flat form of an occlusive artery (in contrast to the culture of conical shape), the presence of side branches at the site of the beginning of the occlusion and the presence of pronounced artery. In connection with technological progress, specialized conductors were developed for the passage of chronic occlusion. The use of new specialized tools with experienced endovascular surgeons led to an increase in the percentage of CHOK recangibles, despite the presence of angiographic predictors of unsuccessful recanabilities, which were described over 15 years ago. Mo1e et al. The preoperative use of multispiral computed tomography in addition to the traditional angiography of coronary arteries in order to determine the predictors of unsuccessful revascularization is evaluated. This study included 49 patients. Conducting MSCT coronary arteries Before CVB really gave additional information. With a multifactoric analysis, 3 predictors of unsuccessful reservation of the CO) were allocated: the presence of

flat form of the occlusive artery identified at kag; The length of occlusion is more than 15 mm and the presence of pronounced calcinosis according to the MSCT.

Pathophysiology occlusion.

Histological study of chronic total occlusions (CHOC) is important for understanding the organization of occlusion and the development of technical approaches in order to increase the interest of recangibles. Occlusion asses up to 3 months rich in lipids, has a more "soft" tire compared to chronic occlusions, which makes it easier to carry out an intra-coronary conductor for occlusion. A more organized COP contains dense fibrous inclusions and has a pronounced calcification (Fig. 1). CHOCE develops after the gap of an atherosclerotic plaque with the formation of a thrombus. In the case of acute occlusion of the coronary artery, it is about the irreversible damage to myocardium in the zone of blood supply to this coronary artery. Thus, an emergency carrying out of permissive coronary intervention (CCV) or the introduction of a thrombolytic preparation is necessary. It is also possible to develop occlusion in the field of long-term existing and gradually increasing stenosis. In this case, a collateral network is formed, and the obstruction of the coronary artery may not be accompanied by a focal mistreatment of myocardium.

Over time, relative to the "soft" thrombus and lipid inclusions are replaced by collagen, with a dense fibrous fabric located at the proximal and distal ends of occlusion - the so-called tires. After about a year, the area of \u200b\u200bocclusion becomes calcined.

Figure 1. Coronary artery of a person with occlusion in the process of organization (A) and artery with organized occlusion (b).

On the side A, the complete occlusion is shown during the organization - the boundaries of occlusion are indicated by arrows. The image visualizes the numerous vascular channels (asterisks) of different sizes, built into the matrix, which is characterized by staining fibrin (red) and proteoglycans (blue-green). On the side B is presented already organized total occlusion. The arrows indicate the boundaries of occlusion, where the vascular channels (asterisks) are surrounded by a saturated collagen matrix (yellow). Both cuts are made at a 20-fold increase. Images are provided by Dr. Frank D. Kolodgie and Renu Virmani, the US Army Pathology Institute, Washington, USA.

Histological examination occlusion confirms the presence of microscopes that cannot be visualized due to the low resolution of the routine kg (250 μm). In fact, more than 75% of occlusions identified during coronary angiography are not fully conclusted by the surveillance of the coronary artery according to histological studies. Microsudes are celebrated on Adventice and Media and, as a rule, go in the radial direction. With sufficient development, they are considered as "bridge collaterals". Neovascularization is also observed in atherosclerotic plaques, as well as within the thrombus as it becomes more and more organized. Microsudes usually reach the size of 100-200 μm, although their dimensions can reach 500 microns. They play a particularly important role in the reconnaissance of the chocas, since there are parallel occlusion and may be by carrying out intrakoronary conductors (0.014 inches conductor, diameter is 360 microns). Strauss et al. reported

on the results of the visualization of microsudes at high resolution On the model of the femoral artery of the rabbit, using magnetic resonance tomography (MRI) and three-dimensional computer microtomography (micro-CT). MRI technologies can provide spatial resolution up to 100-200 microns in one plane. The micro-CT technique is performed by EX-VIVO on excised vessels using a polymer connection with a slight viscosity (Microfil), which fills the microsudes. Micro-CT visualization evaluates microsudes to a resolution of 17 microns. On the basis of the research conducted, 4 morphological components of the CO) were isolated:

Dense fibrous fabric in proximal covering occlusion

Calcification

Microsudes

A distal conclusion tire.

Figure 2. Coronary Angiograms of the Patient B.

Patient B, 71 years, in 1999, suffered a sharp myocardial infarction of the anterior localization. In 1999, a coronary shunting was performed about the three-sidewous damage of the coronary channel (the occlusion of the PNA in the middle segment; the stenosis is 80% in the middle segment of OA, occlusion in the mouth of the 2nd ATC; CCLS occlusion in the proximal segment). Since July 2012, the resumption of angina attacks. In March 2013, a kAg was performed, a chronic occlusion was revealed in the proximal segment of the PKA (a), the post-consilment department is filled with intersystem collaterals, occlusion in the mouth of the shunt to the PKA, the remaining shunts function. According to the echo-kg, the function of the left ventricle is 40% (the hypochesines of the front and front-part-partition segments of LV).

During the procedure, the JR 4-6F catheter was used the initial attempts to use the intrakoronary conductor PT 2 MS (Boston Scientific) were unsuccessful, due to the insufficient rigidity of the conductor tip (b). Recanalization was performed using the intrakoronary conductor Miracle 6 (B). This technology requires greater experience of the operating surgeon and the accuracy of the use of an intrakoronary conductor with a rigid tip. The best conductors with such rigidity to use for rectilinear arteries, because for convinced arteries there is high risk Perforation. G, D: After preliminary predictation with a balloon catheter 3.0 * 20 mm in the place of occlusion, stents 4.0 * 38 mm and 4.5 * 28 mm were sequentially installed. E is the result of stenting.

Proximal tire.

The presence of a dense fibrous tire makes it difficult to carry out an intrakoronary conductor, especially if the form of occlusion is flat. In addition, the discharge of the side branches also makes it difficult to conduct a conductor through occlusion, due to the fact that the coronary conductor is usually deviated to the side branches.

For more successful discharge of CHOC, special intrakoronary conductors are developed, which are better carried out through a dense fibrous occlusion tire. Such conductors may have straight or beveled tips and are separated by tip rigidity. The rigidity of the tip of the intracoronary conductor corresponds to the mass applied to the tip in grams. An example is Miracle (Asahi Intecc, Japan), with gradation 3; 4.5; 6 and 12 grams. As a comparison, a standard flexible conductor has a mass applied to the tip, in order to bend it, less than 1 gram, conductor with an average rigidity of approximately 3 grams. If the mass applied to the tip for its flexion, more than 3 grams, then the intrakoronary conductor is considered tough, and such conductors should be used with extreme caution. An example of an intrakoronar conductor with a bevelled tip can serve a Conquest (Confianza) conductor (Asahi Intecc, Japan), which is a conductor with a diameter of 0.35 mm with a bevelled tip of 0.23 mm and "load" to the tip of 9 grams, as well as the CROSSS conductor IT (Abbott Vascular) with a tip of 0.25 mm and different degrees of stiffness. Improving intracoronary conductors can be achieved when using a guide catheter with improved support, as well as support in the form of a balloon catheter or a micro catheter. An example of the insufficient rigidity of the tip of the intrakoronary conductor during the reconnaissance of the chocus is shown in Figure 2.

As soon as the proximal tire is passed, especially in the "fresh" occlusion, the rest of the occlusion can be easily passing using softer conductors. However, you should not forget that calcined occlusion can be a problem for a further conductor.

Calcification.

Occlusion with a limitation of less than 3 months is characterized by a low degree of calcification, and even a slight rotation of the intrakoronary conductor (< 90) может обеспечить его легкое антеградное проведение. ХОКА с выраженным кальцинозом являются значимым барьером для проведения интракоронарного проводника, а при использовании проводников с жестким кончиком, кальций может стать причиной проведения

the conductor is submatimally (Fig. 3a). The degree of calcification is better to evaluate the multispiral computed tomography, and not coronary angiography. However, this approach is not rational, due to the high cost of research. If the coronary conductor still passed into the subtlematic space, then the technique of parallel conductors can be used. Leaving the conductor in the subtlemal space, to carry out an additional conductor through a true channel. Such an technique sometimes allows you to achieve an intrakoronary conductor even with pronounced calcine (Fig. 3b).

Microsudes.

Neovascularization is the formation of new vascular microchangals both inside occlusion and in other sections of the vascular wall (media, adventure). The number of micrososudes increases with the "age" of occlusion. Neovascularization in COCA may have both the advantages and disadvantages for recitation. When well-developed microsudes go parallel to occlusion, it can facilitate the passage of an intrakoronary conductor. In this situation, coronary conductors with hydrophilic coating behave well, since the coating activated in the liquid helps the conductor easily pass through the channel. These microsudes can be visible or invisible with coronary angiography. When there are signs of antitegrand blood flow (Timi i) through the central channel, the most effective will be hydrophilic coated conductors, such as Crosswire NT (Terumo), Shinobi (Cordis Corporation), Whisper and Pilot (Abbotttt Vascular).

Conductors with a beveled tip can also be used to pass through the microsudes, however, due to their fragility, the risk of perforations with such conductors increase. Bridge collaterals are sometimes highly convulsive and at the apparent acceptable diameter of collateral risk of perforations are also high. In case of identifying collaterals of this type, it is better to use a conductor with a hard tip and conduct it through the central channel of occlusion, ignoring bridge collaterals.

Distal tire.

With extended and convulsions, conducting a conductor through the distal part of the occlusion may be difficult. In such occlusions, the rotation of the end of the intracoronary conductor is significantly difficult. Currently, retrograde is actively used.

Figure 3. Scheme of reconalization of the coronary artery in the presence of chronic occlusion and severe calcinosis.

recanabilization of coronary arteries. With retrograde recanalization through collateral, by means of a micro catheter, an intrakoronary conductor is supplied to the place of occlusion from the distal side retrograde. In many studies, this technique of COCA recangolizations has shown relatively good results compared with the antitegrand reconciliation.

If the rigidity of the tip of the intracoronary conductor is less than the stiffness of calcinosis, the anchor of the intracoronary conductor will be deviated in Figure A presented the devices to the subtlematic space. Use two conductors. In Figure B: The first conductor is in the subtlemal space, as if "blocking" the entrance to the false channel. The second conductor must go parallel to the first on the true channel through occlusion. In this situation, the use of a second intrakoronary conductor with a more rigid and bevelled tip can improve the results of reconalization of coronary arteries, even with severe calcine.

The effectiveness of the implantation of drugs with medicinal coating.

Remote results after stenting the CHOK show a higher percentage of restenosis, compared with the stenting of non-obluso-bathing arteries. Some randomized studies have demonstrated a reliable difference between the implantation of stents and balloon angioplasty (TBKA) in patients after the reconnaissance of the coronary arteries. Published meta-analysis of these studies

demonstrates the lack of difference in mortality (0.4% in the HMS stenting group and 0.7% in a group where only TBKa (OR 0.72, Di 95%, 0.21-2,50) was carried out. Stenting is associated with reliably smaller. An hour of serious adverse cardiac events (MACE): 23.2%, in a stenting group compared with 35.4%, in the TBKA group,

OR 0.49, di 95% 0.36-0.68 due to fewer repeated revascularization (17% in the stenting group against 32% in the TBKA group,

OR 0.4, Di 95% 0.31-0.53).

The results of a number of registers of the implantation of drugs with medicinal coating and HMS (Tables 1 and 2) are published. In the studies used stents covered with Sirolimus (SES) and Pakli-Taxel (PES). In the group where the drugs with drugs were installed, there were significantly fewer side effects, the smaller frequency of restenosis and the need to revascularize the target lesion. Research data confirmed SES effectiveness in comparison with BMS. So, according to the study of PRISON II, the frequency of revascularization in the field of target lesion) was 12% for SES in comparison with 30% for BMS, P \u003d 0.001; Revascular-rising of the target vessel 17% for SES in comparison with 34% for BMS, p \u003d 0.009; Frequency of adverse cardiovascular events (MACE) 12% for SES in comparison with 36% for BMS, P<0,001.

If we take into account the results of all these studies, the frequency of revascularization of the target vessel is significantly lower in the group of patients with medicinal coating stents (Fig. 4).

As for the choice of a drug with a drug at CHOC, then a recently published PRISON III study can be noted - a multicenter, randomized study,

comprising 304 patients. In this study, stents were rated covered with Sirolimus (SES), and the stents covered with Zotaralymus (Zes). Moreover, the coated group by Zotaralims shared on 2 subgroups: patients with stents Endeavor (Medtronic, USA) and patients with RESOLUTE stents (Medtronic, USA). The primary end point was the late loss of the lumen for eight months of observation.

In eight months, patients in the SES group had a smaller late loss in the segment and in the wall in comparison with the group, where SES were installed: -0.13 ± 0.3 mm against 0.27 ± 0.6 mm (p \u003d 0, 0002) and -0.13 ± 0.5 mm against 0.54 ± 0.5 mm (p<0,0001), соответственно. В группе SES и в группе ZES результаты оказались сопоставимы по потере просвета в сегменте -0,03±0,7 мм против -0,10±0,7 мм, p=0,6 и в стенте 0,03±0,8 мм против 0,05±0,8 мм, p=0,9.

For 12 months of observation, there was no significant difference in the number of large adverse cardiovascular events in the group where SES and in the Zes group 11.8% were established against 15.2%, p \u003d 0.8; Revascularization in the field of targeted lesion is 9.8% against 15.2%, p \u003d 0.5 and deficiency of the target vessel 11.8% against 15.2%, p \u003d 0.8. The SES and ZES group also did not indicate a reliable difference in the amount of Mace: 5.8% against 7.7%, p \u003d 0.8; TLR 5.8% against 3.8%, p \u003d 0.5; TVR 5.8% against 5.8%, p \u003d 1.0, there was also no difference in thrombosis of stents of 1.0% in both groups.

Own data.

A few years ago, studies of successful recanalysis were conducted in the Department of X-ray-strict diagnostics and treatment of the RK NPK. In 208 patients with IBS, the reservations of CHOK were performed. 170 patients (81.5%) were male and 38 (18.5%) female. The age of patients ranged from 36 to 68 years (on average 52 years). Terms of occlusion from 1 month to 3 years. Myocardial infarction in history had 164 patients (78.5%). Multi-propelled lesion was detected in 169 patients (81.2%), single-sideways in 37 patients (17.8%). "Silent" occlusion with the preserved contractivity of myocardium had 46 patients (22.1%). Successfully restore blood flow managed in 154 patients (74%). In 58 (26%) patients, recanalization was unsuccessful due to the impossibility of carrying out an intrakoronary conductor through the OK-KORZY tire. Use: BMS - uncovered metal stent, MACE - serious adverse cardiac events; NS - not significantly; PES - stent covered by paclitaxel; SES - stent coated with syrolimus; TLR - Revascularization of the target lesion.

Conclusion.

The renovalization of the CTC is currently remaining technically complex interference for many interventional cardiologists. Although over the past 5-10 years in the Arsenal, endovascular surgeons have a large set of specialized coronary conductors. The introduction of new methods and specialized tools allows you to achieve successful recanalization by more than 80% occlusion in the hands of an experimental operator.

Histological studies have shown the presence of microscopes in the area of \u200b\u200bocclusion, which sometimes contributes to the favorable reconalization of the coronary arteries. To improve the results of the reservation of the COC, the most rationally slow conduct of the intrakoronary conductor through an occlusive area. It is recommended that the use of multiple intrakoronary conductors or the choice of the best conductor for specifically this occlusion. After conducting a conductor through occlusion and dilatation with a balloon catheter, it is recommended to use drugs with drugs.

Table 1. Scheme of reconalization of the coronary artery in the presence of chronic occlusion and severe calcinosis.

Register Research BMS Register Milan BMS Prison II BMS Nakamura et al BMS Werner Etal BMS T-Search Pes

BMS SES P BMS SES P BMS SES P BMS SES P BMS SES P

Number of patients 28 56 259 122 100 100 120 60 48 48 57

Observation duration (months) 12 12 6 6 60 60 12 12 12 1 2 12

Clinical outcomes

Death (%) 0 0 - 1 3 0,61 5 5 1,0 0 0 - 4 2 NS 2

They (%) 0 2 NS 8 8 0.97 7 8 0.8 3 0 NS 2 4 NS 2

TLR (%) 18 4<0,05 26 7 <0,001 27 12 0,006 42 3 0,001 44 6 <0,001 4

Masa (%) 18 4<0,05 35 16 <0,001 36 12 0,001 42 3 0,001 48 13 <0,001 7

30-day stanta thrombosis 0 2 NS 0.4 0 0,70 1 7 NS 0 0 - 0 0 - 0

Note: In MS - uncovered metal stent; Masa - serious adverse cardiac events; NS - not significantly; PES - stent; pacpitaxel; SES - stent; syrolimus coated; TLR - Revascularization of the target lesion.

Atherosclerosis and dyslipidemiy

Figure 4. The risk of need for repeated revascularization in patients who are exposed to the implantation of drugs with drug coating (BC) in comparison with Golossomemarket stents (VBM) within each study and in the general population with an indication of the OR and 95% di.

Research Des (n | n) BMS (n | n) or (random) 95% Dt Sampling in% or (random) 95% DT

Hoye et al | in 1/56 5/28< ■ ■ -* I -■-г I -■- V I I 4.10 0.08

KIM ET ALLIG 1/54 10/79 4.56 0.13

GE ET ALL17 11/122 75/259 43.57 0.24

Nakamura et al12 2/60 51/120 9.38 0.05

SUTTORP ET ALL15 8/100 22/100 26.64 0.31

Werner et al15 3/48 21/48 11.75 0.09

Total (95% di) 440 634 100 0.18

General chamber of events: 26 (BC), 184 (VBM) Generalized effect estimate: 7 \u003d 7.48, (p<0.00001)

0.01 0.1 1 10 100

Table 2. An overview of the angiographic results of published studies, within which the implantation of stents excluding the drugs, with chronic total occlusions, was estimated.

Register Research)