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CLINICAL RESEARCH: INTERVENTIONAL CARDIOLOGY

Intracoronary Fibrin-Specific Thrombolytic Infusion Facilitates Percutaneous Recanalization of Chronic Total Occlusion

William Beaumont Hospital, Royal Oak, Michigan

Manuscript received March 25, 2005; revised manuscript received May 2, 2005, accepted May 10, 2005.

^_* Reprint requests and correspondence: Dr. William W. O’Neill, Division of Cardiology, William Beaumont Hospital, 3601 West 13 Mile Road, Royal Oak, Michigan 48073 (Email: woneill{at}beaumont.edu).

OBJECTIVES: We sought to investigate the benefit, predictors of procedural success, and safety of pre-procedural intra-coronary fibrin-specific lytic infusion (ICL) in patients with failed prior percutaneous coronary intervention (PCI) for chronic total occlusions (CTO).

BACKGROUND: Percutaneous coronary intervention for CTO remains a challenge with a high incidence of procedural failure secondary to inability to cross the occlusion with the guidewire.

METHODS: Eighty-five patients who underwent unsuccessful PCI procedures of CTO (more than three months’ duration) had a repeat attempt of recanalization with the use of pre-procedural ICL. Patients received a weight-adjusted dose of either alteplase (tPA) (2 to 5 mg/h) or tenecteplase (TNK) (0.5 mg/h) for a total of 8 h. The total dose of ICL therapy was infused split between the guiding catheter and an intracoronary infusion catheter. A step-down multivariate logistic regression analysis was completed to determine the best predictors of procedural success. In-hospital major adverse cardiac events (MACE) including myocardial infarction, acute reocclusion, stroke, and death, as well as bleeding complications, were also examined.

RESULTS: The procedure was successful in 46 of 85 cases (54%). Four of 85 (5%) contained dissections that did not result in perforations, tamponade, or MACE. The incidence of groin complications was 7 of 85 (8%) and of bleeding complications requiring transfusions was 3 of 85 (3.5%). On multivariate analysis, predictors of success were tapering morphology (odds ratio, 15.5; 95% confidence interval, 3.73 to 63; p = 0.0002) and lack of bridging collaterals (odds ratio, 5.08; 95% confidence interval, 1.53 to 17; p = 0.008).

CONCLUSIONS: Intracoronary infusion of fibrin-specific thrombolytic therapy may provide a valuable and safe option for facilitating percutaneous revascularization of CTO.

Abbreviations and Acronyms   CTO = chronic total occlusion   ICL = intracoronary lytic therapy   MACE = major adverse cardiac events   MI = myocardial infarction   PCI = percutaneous coronary intervention   RCA = right coronary artery   TIMI = Thrombolysis In Myocardial Infarction   TNK = tenecteplase   tPA = alteplase

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