RU2302267C2 - Method for removing occlusion of coronary artery - Google Patents

Abstract

FIELD: medicine, cardiosurgery.

SUBSTANCE: the present innovation deals with reconstructing permeability of occluded coronary arteries due to removing occlusion out of affected parts of arteries. So, a coronary guide with a soft tip should be applied to achieve the site of occlusion by not entering a lateral artery. As balloon catheters one should apply two-lumen ones, moreover, the first is designed to be shortened from its distal edge and ends with a balloon segment. The present balloon catheter should be applied up to the site of occlusion onset and simultaneously up to bifurcation region to install it, to be blown up to overlap the mouth of lateral artery. Then a rigid direct guide should be applied along the same balloon catheter - according to its conduit mine after preliminary removing a coronary guide with a soft tip. After directing this rigid guide through occlusion into distal part of occluded main artery and its recanalization with it is important to remove the first modeled balloon catheter and apply the second balloon catheter instead. It should be moved along occlusion to reach the center and dilate the artery. In particular case, one should remove a two-lumen tip by not interrupting the hermetic nature of a balloon catheter. The innovation enables to remove occlusion of the main artery in the site of branching, exclude "falling down" of coronary guide into lateral artery and, thus, provide the disposition of coronary guide especially in the stump in occluded artery and obtain its central position and movement strictly along the center of occlusion avoiding vascular wall traumatism due to subintimal application of coronary guide and, also, avoid arterial perforation in the site of occlusion.

EFFECT: higher efficiency.

1 cl, 7 dwg, 1 ex

Description

The invention relates to the field of cardiac surgery and can be used to restore patency of the occluded coronary arteries by eliminating occlusion in the affected areas of the arteries. It is recommended for use in the place where the lateral artery departs from the main artery, called bifurcation in the literature, when the occlusion is located in the immediate vicinity of the place where the named arteries diverge.

A known method of recanalization of chronic occlusion [Endovascular course of coronary and peripheral therapy. Ninth Complex Coronary Angioplasty Course, Endovascular Therapy Course Coronary and Peripheral, Paris, may 5-8, 1998 Ninth Complex Coronary Angioplasty Course, Jean Marco, Jean Fajadet, CD-ROM], in which, after installing the guide catheter in the occluded artery, a hard one is inserted into it the coronary conductor (with a rigid tip) of the L-shape, after which they bring the latter to occlusion and rest it in the stump of the artery. Then, the coronary conductor passes through occlusion through smooth rotation and turns to the right and left around its axis. recanalization of the latter. Next, the coronary conductor is carried out to the distal end of the artery and a balloon catheter is delivered through it. Then, by ballooning the balloon catheter, the final elimination of occlusion is achieved.

The disadvantage of the described method is that in it, due to the impossibility of accurately entering the center of the artery and further centering the coronary conductor along the occlusion, the subintimal conductor is highly likely to conduct — the illustration in FIG. 3 and its artery wall perforation — the illustration in FIG. 4 when trying to recanalize .

Another disadvantage of it is that when the lateral artery is near the stump, there is an extremely high probability of getting - "stalling" of the coronary conductor into the lateral artery - illustration in Fig. 5.

There is also a method of conducting a coronary conductor during occlusion of the lumen of the coronary artery [p.82, Coronary angioplasty, A.M. Babunashvili, I.Kh. Rabkin, V.A. Ivanov - M .: Publishing house ASV, 1996, 352 p. with ill.,]. In this method, first the tip of the conductor is guided into the stump of the occluded artery and then the balloon catheter is strung onto the conductor so that the tip of the catheter is brought to the beginning of the occluded segment, and the balloon catheter is placed in the stump of the artery. The tip of the conductor is carried out into the distal segments beyond the occlusion zone of the blocked artery only after mechanical recanalization of the occluded part of the artery with a balloon catheter and the tip of the balloon catheter getting distal to the occluded section.

The disadvantage of this method is the high probability of trauma to the intima of the occluded artery and its perforation with the tip of a balloon catheter. Another disadvantage of this method is the risk of embolization of the distal bed with fragments of a destroyed atherosclerotic plaque - illustration in Fig.6 due to manipulations with the tip of the balloon catheter. The third disadvantage is the possibility of the tip of the balloon catheter getting into the lateral branch when the occlusion is located at the bifurcation site.

Closest to the claimed is a method of eliminating chronic occlusion of the main artery, localized directly near the lateral branch, i.e. at the bifurcation site. With this method, two coronary conductors are used. First, a J-shaped coronary conductor with a soft tip is used, which is conducted into the lateral artery. A balloon catheter is inserted along it, which is inflated at the mouth of the lateral artery, thereby blocking it. The second coronary conductor of the rigid L-shape is the recanalization of occlusion. A balloon catheter is inserted along a rigid conductor and inflated to eliminate occlusion [The Parise course on revascularization, 2001, Chronic Total Occlusion, Bernard Chevalier, Thierry Royer, Philippe Guyon, Bernard Glatt - Paris revascularization course, 2001, Chronic total occlusion, CD -ROM].

The disadvantage of this method is the possibility of sub-optimal conductor conduction and the risk of artery perforation when conducting a coronary conductor through occlusion, which is explained by the difficulty of centering the conductor, as well as the possibility of trauma to the intima in the mouth of the lateral artery with a balloon.

Another disadvantage is the likelihood of a second coronary conductor falling into a “trap” between the open balloon segment and the orifice of the lateral artery — see FIG. 7.

The objective of the invention is to prevent possible trauma to the arteries, taking into account the anatomical location of the occlusion, at the bifurcation site by ensuring maximum overlap of the lateral artery exit point to prevent the coronary conductor from slipping into it and allowing passage through the resulting occlusion in the central direction without trauma to the artery walls.

The invention is illustrated using figures 1-7, where

figure 1 - illustration of the proposed method with a swollen first simulated balloon catheter;

figure 2 is an illustration of the same with the folded balloon segment;

figure 3 is an illustration of a subintimal institution of the coronary conductor;

figure 4 - illustration of perforation of the artery with a coronary conductor;

figure 5 is an illustration of the entry of the coronary conductor into the lateral artery;

figure 6 - illustration of embolization of the distal bed;

Fig.7 is an illustration of the conductor falling into a "trap" between the mouth of the lateral artery and the inflated balloon segment located in it.

In the aforementioned figures 1-7, the positions indicated: 1 - balloon segment of the balloon catheter, 2 - rigid straight coronary conductor, 3 - occlusion, 4 - lateral branch of the artery, 5 - bifurcation site, 6 - main artery, 7 - embolization of the distal channel, 8 - coronary conductor with a soft tip.

The essence of the proposed method lies in the fact that in the method of eliminating occlusion of the coronary artery, which consists in recanalization and further elimination of occlusion located at the site of bifurcation - the divergence of the lateral and main arteries, including first establishing a coronary conductor with a soft tip, then introducing a balloon catheter and inflating it, providing blocking of the mouth of the lateral artery, then insertion of a second direct rigid coronary conductor into the occluded artery with subsequent recanal by occlusion and insertion of a second balloon catheter through it to complete occlusion elimination, the coronary conductor with a soft tip is brought to the occlusion site, preventing it from entering the lateral artery, double-lumen is used as balloon catheters, the first made shortened from the distal edge, ending directly balloon segment, the institution of this balloon catheter is carried out to the place of the beginning of occlusion and at the same time to the place of bifurcation, install it in this place and, inflating it oh, they block the entrance to the mouth of the lateral artery, then a hard straight conductor is guided through the same balloon catheter - along its guide shaft after preliminary removal of the coronary conductor with a soft tip from it, and after passing the hard conductor through the occlusion into the distal part of the occluded main artery and they recanalize it, remove the first simulated balloon catheter and insert a second balloon catheter in its place, promote it by occlusion, seeking to find it in the center of it, and dilate it.

In addition, the claimed method with additions, providing for the modeling of a balloon catheter for implementing the method according to claim 1, in which, after the first coronary conductor is inserted before the double-lumen balloon catheter is inserted, the latter is modeled by removing its distal tip without violating the tightness of the latter, giving the balloon catheter with the sides of the distal end form a shortened catheter ending directly with the balloon segment.

The technical result of the proposed method is that when eliminating the occlusion of the main artery in the place of departure of the lateral branches, it eliminates the "stalling" of the coronary conductor in the lateral artery and, thereby, ensures the location of the coronary conductor in the stump in the occluded artery, and also achieve it the central location and advancement of it strictly in the center of occlusion, excluding trauma to the vascular wall due to sub-optimal conduction of the coronary conductor, and also to exclude Arterial perforation at the site of occlusion.

The inventive method is as follows.

After diagnosis and indications for surgical treatment, the patient is performed coronarography to determine the site of the affected artery. Access to the affected artery and further manipulations are carried out under X-ray control. Access is made to the coronary artery using any of the standard approaches (femoral, radial, axillary) by installing a guide catheter through the introducer sheath. A peripheral artery is punctured under local anesthesia, an introducer is inserted into it, and a guide catheter is placed at the mouth of the coronary artery. A coronary conductor with a soft tip, for example, L-shape, is inserted into the occluded artery along the main artery and carried through this artery to the place of occlusion. Among the classical methods of eliminating occlusion, there are practically no special methods for working in a bifurcation site, where there are additional difficulties caused by anatomical features. In order to access this place in the best way, a double-lumen balloon catheter without a distal tip or at least with a shortened tip is necessary. This can be done, for example, by modeling from a conventional balloon catheter by removing the distal tip, for example, by carefully cutting it in a designated place where it is possible to ensure that the balloon segment is not depressurized.

Then, a double-lumen balloon catheter is inserted along the first conductor with a soft tip, in one shaft of which there is now a coronary conductor, through which it passed to the place where the occlusion began, which is significant in this claimed method.

This balloon catheter is brought to the extent of maximum contact with the occlusion surface - to the stop. Then, by supplying the sufficient deflector with sufficient pressure, the balloon is inflated, as a result of which the entrance to the mouth of the lateral artery is closed and the catheter guide shaft is centered with respect to the occlusion surface. Having performed this procedure, a coronary conductor with a soft tip is removed from the balloon catheter and a hard straight coronary conductor is inserted in its place. It is brought to occlusion strictly in the center of it, which is facilitated by the above-described inflated balloon catheter, then, by moving the rigid coronary conductor forward, occlusion is recanalized. After conducting a rigid coronary conductor through occlusion, the first modified balloon catheter is removed. In its place, a second standard balloon catheter with a regular tip is inserted and is promoted through occlusion, seeking to be located in the center of it. Having placed the second balloon catheter in the center of occlusion, dilate it by applying a pressure deflector sufficient to eliminate occlusion. After elimination of occlusion, the second balloon catheter is removed. Coronary angiography is performed to evaluate the outcome of the intervention. The procedure ends with the removal of all instruments from the artery and the application of a pressing aseptic dressing at the puncture site of the peripheral artery.

Example.

Patient K., 57 years old (I.B. No. 1407), was admitted to the clinic. Clinical diagnosis at admission: CHD, angina pectoris III f.k.

Anamnesis of coronary heart disease, when the first attacks of typical angina pectoris began to occur. Deterioration of health, when the tolerance to physical activity decreased, was treated permanently in the clinic. At admission, the clinical symptoms of angina remained at the level of F. f.c. Entered for coronary angiography and determination of indications for surgical treatment.

Upon receipt, the general condition is satisfactory. Heart sounds are muffled, rhythmic. Heart rate - 52 beats per min. Blood pressure 120 and 80 mm Hg There are no signs of circulatory failure. No heart rhythm disturbances. The pulsation on the peripheral arteries is preserved, good filling.

General and biochemical analysis of blood within normal limits. Electrocardiogram (ECG) of the patient at rest: sinus rhythm 52 min, no signs of focal - cicatricial myocardial lesions were detected. ST segment on the contour. During the daily monitoring of the ECG periods of the dynamics of the ST segment were not detected. When conducting a treadmill test against the background of a load corresponding to 4.6 metabolic units, a typical angina attack developed with a ST segment depression of up to 3 mm.

The result of ECHO cardiography - the cavity of the heart of normal size and violations of local contractility was not detected. Left ventricular ejection fraction - 60%.

Coronary Angiography Left type of myocardial blood supply. The left anterior descending artery and the right coronary artery are not changed. There is occlusion in the proximal third of the envelope of the artery immediately after the departure of the first branch of the obtuse margin. The mouth of the first branch of the blunt margin is not stenotic.

Due to the ineffectiveness of drug therapy, it was decided to recanalize occlusion of the envelope of the artery. As a tactic of recanalization of occlusion of the envelope of the artery, the claimed developed method is selected in exact accordance with the claimed methodology. During angioplasty, immediate angiographic success was achieved.

A week after recanalization of occlusion, the patient underwent a treadmill test: the test was negative, and exercise tolerance was high. In the intrahospital period, the complete disappearance of the symptoms of angina pectoris and objective signs of myocardial ischemia was noted. The patient was discharged from the hospital.

When conducting a treadmill test after 8 months, objective signs of myocardial ischemia were not detected.

Claims (2)

1. A way to eliminate occlusion of the coronary artery, which consists in recanalization and further elimination of occlusion located at the site of bifurcation - the divergence of the lateral and main arteries, including the first introduction of the coronary conductor with a soft tip, then a balloon catheter along it and inflating it, then the second hard coronary guide to the occluded artery with its subsequent recanalization and insertion of a second balloon catheter through it to complete the elimination of occlusion, characterized in that to the oronar conductor with a soft tip is brought to the place of occlusion, preventing it from entering the lateral artery, double-lumen are used as balloon catheters, the distal end being modeled in the first so that it ends directly with the balloon segment, this catheter is brought to the occlusion site - the bifurcation site , install it in this place and inflate it, blocking them from entering the mouth of the lateral artery, then a hard straight conductor is inserted into one of the shafts of the balloon catheter after preliminary removal from a coronary conductor with a soft tip, recanalize it, conducting it to the distal part of the occluded main artery, remove the first simulated balloon catheter and insert a second balloon catheter in its place, advance it to the occlusion site, dilate the occluded artery. 2. The method according to claim 1, characterized in that the double-lumen balloon catheter is modeled by shortening its distal tip without compromising tightness, while the catheter ends directly with the balloon segment.

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