Case report
Percutaneous coronary intervention due to chronic total occlusion in the left main coronary artery after bypass grafting: A feasible option in selected cases
Intervenção coronária percutânea de oclusão crónica total do tronco comum após pontagem coronária: uma opção possível em casos selecionados
Eduardo Flores-Umanzor
, Victoria Martin-Yuste, Guillem Caldentey, Sara Vazquez, Gustavo Jimenez-Britez, Rodolfo San Antonio, Pedro Cepas-Guillen, Margarida Pujol-Lopez, Marco Hernández, Manel Sabaté
Corresponding author
University of Barcelona, Cardiology Department, Cardiovascular Institute, Barcelona, Spain
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(A) Two-dimensional transesophageal echocardiogram, left ventricular outflow tract projection; (B) computed tomography curved format reconstruction along the catheter; (C) three-dimensional volume-rendered computed tomography reconstruction of the catheter insertion point and its relationship with the anterior descending artery.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Manuel Barreiro-Perez, Ana Martin-Garcia, Marta Alonso-Fernández de Gatta, Pedro L. Sanchez" "autores" => array:4 [ 0 => array:2 [ "nombre" => "Manuel" "apellidos" => "Barreiro-Perez" ] 1 => array:2 [ "nombre" => "Ana" "apellidos" => "Martin-Garcia" ] 2 => array:2 [ "nombre" => "Marta" "apellidos" => "Alonso-Fernández de Gatta" ] 3 => array:2 [ "nombre" => "Pedro L." "apellidos" => "Sanchez" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2174204918303507?idApp=UINPBA00004E" "url" => "/21742049/0000003700000010/v1_201810310641/S2174204918303507/v1_201810310641/en/main.assets" ] "itemAnterior" => array:20 [ "pii" => "S2174204918303106" "issn" => "21742049" "doi" => "10.1016/j.repce.2017.10.014" "estado" => "S300" "fechaPublicacion" => "2018-10-01" "aid" => "1221" "copyright" => "Sociedade Portuguesa de Cardiologia" "documento" => "article" "crossmark" => 1 "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/" "subdocumento" => "rev" "cita" => "Rev Port Cardiol. 2018;37:859-63" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 656 "formatos" => array:3 [ "EPUB" => 96 "HTML" => 359 "PDF" => 201 ] ] "en" => array:12 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Review Article</span>" "titulo" => "Proton pump inhibitors and the risk of severe adverse events – A cardiovascular bombshell?" 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Its actual prevalence and incidence are unknown, although an incidence of 0.04% was reported in a large series.<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">1,2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">A more insidious clinical presentation, consisting of stable angina, unstable angina, and dyspnea, predominates in the presence of CTO of the LMCA, as opposed to acute lethal cardiac events resulting from acute thrombotic occlusion.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">1</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">With CTO of the LMCA comes a risk of major cardiovascular events, such as death from ischemic anterior myocardium, despite collateral circulation.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">2</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Revascularization is recommended in the presence of demonstrated viability or ischemia in the area of the compromised perfused artery. Coronary artery bypass grafting (CABG) has long been considered the preferred option in this situation. Though limited evidence is available, promising results have been seen after percutaneous coronary intervention (PCI) using new-generation drug-eluting stents.<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">2,3</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Patients with a previous CABG due to LMCA disease with occlusion of one graft and progression of the LMCA to CTO constitute a special population, as just one ischemic artery remains (circumflex or left anterior descending artery), for which there is no other revascularization option other than cardiac surgery (requiring resternotomy) or PCI of the LMCA.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Methods</span><p id="par0030" class="elsevierStylePara elsevierViewall">Out of 620 patients with CTO diagnosed in our center, we identified five with a previous CABG due to LMCA disease for a retrospective case series. They had occlusion of one graft and progression of the LMCA to CTO. All five underwent PCI. Each patient received a functional classification for angina, myocardial ischemic tests such as cardiac magnetic resonance imaging (cMRI), myocardial perfusion scintigraphy, and a follow-up coronary angiogram during a median follow-up of 63 months (range 16-118 months).</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Results</span><p id="par0035" class="elsevierStylePara elsevierViewall">Median age was 65 years (range 46-82 years), and all patients were male. All of them had at least three traditional cardiovascular risk factors and one had chronic renal disease (<a class="elsevierStyleCrossRefs" href="#tbl0005">Tables 1 and 2</a>).</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall">Three patients presented with new-onset crescendo angina reaching III/IV on the Canadian Cardiovascular Society (CCS) angina grading scale, and two had acute coronary syndrome (non-ST elevated myocardial infarction). The coronary angiogram showed CTO of the semi-protected LMCA lesions with two coronary artery bypass grafts previously performed in all patients, one occluded and the other patent (<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>). Three patients had saphenous vein grafts to the circumflex coronary artery that were CABG occluded and two patients had left internal mammary artery-left anterior descending artery CABG failure. A coronary CT angiography was performed in one patient to better visualize the CTO (<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0045" class="elsevierStylePara elsevierViewall">Severe left ventricular dysfunction (LVD) was found in one patient, and moderate LVD was found in three. Ischemia and viability were demonstrated in four patients by cMRI with adenosine (one patient) or perfusion scintigraphy (three patients). Surgery was ruled out either because of patient refusal or because of high surgical risk. Four patients with semi-protected lesions successfully underwent anterograde PCI of the LMCA with drug-eluting stents using the standard antegrade wire escalation technique (<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>). No debulking technique was used in patients with heavily calcified left main (LM) lesion. The retrograde technique was used in one patient through the septal channel. In this case, LM occlusion was located at the ostium.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0050" class="elsevierStylePara elsevierViewall">In a five-year follow-up, four patients remained asymptomatic (CCS Grade I for angina and New York Heart Association Class I) and event-free (no major adverse cardiac events). Perfusion defects were not detected in repeat cMRIs with adenosine or perfusion scintigraphies, and no coronary disease progression was found at 63-month follow-up. Three patients experienced a 10% improvement in left ventricular ejection fraction.</p><p id="par0055" class="elsevierStylePara elsevierViewall">Unfortunately, one death occurred 1.4 years post-PCI from non-cardiovascular cause (cancer).</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Discussion</span><p id="par0060" class="elsevierStylePara elsevierViewall">The need for repeated interventional procedures in patients after CABG is determined by the durability of the bypass graft and progressive atherosclerosis of native coronary arteries. It has been assumed that changes in intracoronary circulation following the insertion of bypasses lead to the progression of native artery stenotic lesions to CTO.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">3</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">This case series is significant because this special population often suffers from refractory angina. Moreover, mortality is extremely high without intervention.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">3</span></a> Traditionally, a new surgical bypass approach was considered to be the treatment of choice for these patients. However, in daily practice, the high surgical risk profile resulting from multiple comorbidities and re-intervention commonly leaves PCI as the only feasible option.</p><p id="par0070" class="elsevierStylePara elsevierViewall">With the advent of new drug-eluting stents and improvements in techniques, PCI can be a successful and safe procedure in this setting and can provide sustained clinical improvements, as observed in our small series.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Authorship</span><p id="par0075" class="elsevierStylePara elsevierViewall">All authors had access to the data and played a role in writing this manuscript.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Conflicts of interest</span><p id="par0080" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:3 [ "identificador" => "xres1101182" "titulo" => "Abstract" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods and Results" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1042023" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1101181" "titulo" => "Resumo" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "abst0020" "titulo" => "Introdução" ] 1 => array:2 [ "identificador" => "abst0025" "titulo" => "Métodos e resultados" ] 2 => array:2 [ "identificador" => "abst0030" "titulo" => "Conclusões" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1042024" "titulo" => "Palavras-chave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Methods" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Authorship" ] 9 => array:2 [ "identificador" => "sec0030" "titulo" => "Conflicts of interest" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2017-01-11" "fechaAceptado" => "2017-03-08" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1042023" "palabras" => array:3 [ 0 => "Chronic total occlusion" 1 => "Left main coronary artery" 2 => "Coronary artery bypass grafting" ] ] ] "pt" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palavras-chave" "identificador" => "xpalclavsec1042024" "palabras" => array:3 [ 0 => "Oclusão crónica total" 1 => "Tronco comum coronário" 2 => "Cirurgia coronária" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Chronic total occlusion (CTO) of the left main coronary artery (LMCA) is an infrequent finding. Revascularization is recommended in the presence of demonstrated viability or ischemia. Coronary artery bypass grafting (CABG) has long been considered the preferred option. Patients with previous CABG due to LMCA disease with occlusion of one graft and progression of the LMCA to CTO constitute a special population, as just one ischemic artery remains. For these patients, there is no other option for revascularization other than cardiac surgery (requiring resternotomy) or percutaneous coronary intervention (PCI) of the LMCA.</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods and Results</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Out of 620 patients with CTO diagnosed in our center, we identified five with previous CABG due to LMCA disease for a retrospective case series. They had occlusion of one graft and progression of the LMCA to CTO. All five underwent PCI. Each patient received a functional classification for angina, myocardial ischemic tests, and a follow-up coronary angiogram during a median follow-up of 63 months. Coronary angiogram showed CTO of the semi-protected LMCA lesions with two CABGs previously performed in all patients, one occluded and the other patent. Three patients had occluded saphenous vein grafts to the circumflex coronary artery, and the rest had left internal mammary artery-left anterior descending artery CABG failure. Ischemia and viability were demonstrated. Surgery was ruled out due to high surgical risk. PCI due to CTO of the LMCA with drug-eluting stents was performed. In a five-year follow-up period, four patients remained asymptomatic and event free. One post-PCI death occurred from non-cardiovascular cause.</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Conclusions</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">PCI due to CTO of the LMCA following CABG can be successful and safe and can provide sustained clinical improvements in selected cases.</p></span>" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods and Results" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Conclusions" ] ] ] "pt" => array:3 [ "titulo" => "Resumo" "resumen" => "<span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Introdução</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">A oclusão crónica total (OCT) do tronco comum (TC) coronário é um achado pouco frequente. A revascularização é recomendada na presença de viabilidade ou de isquemia comprovada. A <span class="elsevierStyleItalic">coronary artery bypass grafting</span> (CABG) tem sido durante muito tempo a opção preferencial. Os doentes com CABG prévia devida a doença do TC com oclusão de um enxerto e progressão para oclusão crónica total do tronco comum constituem uma população especial, uma vez que fica apenas uma artéria com isquemia. Para esses doentes não existe outra opção de revascularização além da cirurgia cardíaca – com necessidade de reesternotomia – ou a intervenção coronária percutânea do tronco comum.</p></span> <span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Métodos e resultados</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Dos 620 doentes com oclusões coronárias totais diagnosticadas no nosso centro, identificamos como séries de casos retrospetivos, cinco com CABG prévia devida a doença do TC, que tinham uma oclusão de um enxerto e progressão da doença do TC para oclusão crónica total. Os cinco foram submetidos a intervenção coornária percutânea (ICP). Cada doente recebeu a classificação funcional de angina, de testes de isquemia do miocárdio e o seguimento com angiografía coronária durante o tempo médio de 63 meses de seguimento. O angiograma coronário mostrou oclusão coronária total das lesões semiprotegidas do TC com duas pontagens previamente feitas em todos os doentes, uma ocluída e a outra permeável. Três doentes tinham enxertos de veia safena para a artéria coronária circunflexa (Safena-CX) ocluídos e os restantes tinham insuficiência da pontagem com mamária interna esquerda para a artéria coronária descendente anterior (MIE-DA). Foi demonstrada isquemia ou viabilidade. A opção cirúrgica foi recusada devido ao elevado risco cirúrgico. Foi feita a ICP da oclusão coronária total do TC com <span class="elsevierStyleItalic">stents</span> revestidos de fármaco. Em cinco anos de seguimento, quatro doentes permaneceram assintomáticos e livres de eventos. Ocorreu uma morte após ICP devido a causa não cardiovascular.</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conclusões</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">A ICP de oclusão crónica total do TC após CABG pode ser bem-sucedida, segura, e pode fornecer melhorias clínicas mantidas em casos selecionados.</p></span>" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "abst0020" "titulo" => "Introdução" ] 1 => array:2 [ "identificador" => "abst0025" "titulo" => "Métodos e resultados" ] 2 => array:2 [ "identificador" => "abst0030" "titulo" => "Conclusões" ] ] ] ] "multimedia" => array:4 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1518 "Ancho" => 2000 "Tamanyo" => 284691 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">(A and B) Coronary angiogram showing chronic total occlusion of the left main coronary artery and critical left anterior descending lesion proximal to left internal mammary artery anastomosis; (C) coronary computed tomography angiography showing a short (9 mm), hardly calcified chronic total occlusion lesion: in the middle of the occlusion 100% of the coronary lumen (186 Hounsfield units) was calcified and, in the distal part, 75% of the wall circumference (933 Hounsfield units) was calcified.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1187 "Ancho" => 1583 "Tamanyo" => 136670 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Successful anterograde percutaneous coronary intervention due to chronic total occlusion of the left main coronary artery with drug-eluting stent.</p>" ] ] 2 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">LVEF: left ventricular ejection fraction.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Case \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Age \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Gender \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Angina grading scale \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Hypertension \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Chronic renal failure \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Type 2 diabetes \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Dyslipidemia \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Smoker \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Baseline LVEF \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">EuroSCORE II \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">48 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Male \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">III \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">45% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4.7% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">70 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Male \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">II \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">40% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6.7% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">46 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Male \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">II \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">40% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7.17% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">82 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Male \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">II \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">30% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">34.39% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">72 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Male \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">II \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">50% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7.88% \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1884087.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Demographic/clinical characteristics.</p>" ] ] 3 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">CABG: coronary artery bypass grafting; cMRI: cardiac magnetic resonance imaging; LIMA-LAD: left internal mammary artery-left anterior descending artery; LRA-OM: left radial artery-obtuse marginal artery; SPECT: single-photon emission computed tomography; SVG-CX: saphenous vein-circumflex coronary artery.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Case \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">LIMA-LAD CABG \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">SVG-CX CABG \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">LRA-OM CABG \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Myocardial ischemic tests (cMRI or cardiac SPECT) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Type of stent \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Follow-up \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Cypher \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">118 months \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Xience \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">60 months \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Xience \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">58 months \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Xience \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">63 months \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Xience \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">16 months \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1884086.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Coronary angiographic findings, myocardial ischemic tests performed and follow-up.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:3 [ 0 => array:3 [ "identificador" => "bib0020" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Successful percutaneous coronary intervention of total chronic occlusion of the left main coronary artery: a feasible option?" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "E. Flores-Umanzor" 1 => "M. Hernández-Enríquez" 2 => "G. Jimenez Britez" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.ijcard.2016.11.227" "Revista" => array:6 [ "tituloSerie" => "Int J Cardiol" "fecha" => "2017" "volumen" => "229" "paginaInicial" => "19" "paginaFinal" => "20" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/27876542" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0025" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Successful percutaneous coronary intervention for acute and chronic occlusion of the left main coronary artery: report of two cases and review of the literature" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "G.Z. Ma" 1 => "Y. Wang" 2 => "R.H. Xu" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.2143/AC.71.2.3141841" "Revista" => array:6 [ "tituloSerie" => "Acta Cardiol" "fecha" => "2016" "volumen" => "71" "paginaInicial" => "127" "paginaFinal" => "134" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/27090033" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0030" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Chronic total occlusion: to treat or not to treat" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "A. Bardají" 1 => "J. Rodriguez-López" 2 => "M. Torres-Sánchez" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.4330/wjc.v6.i7.621" "Revista" => array:6 [ "tituloSerie" => "World J Cardiol" "fecha" => "2014" "volumen" => "6" "paginaInicial" => "621" "paginaFinal" => "629" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25068022" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/21742049/0000003700000010/v1_201810310641/S2174204918303787/v1_201810310641/en/main.assets" "Apartado" => array:4 [ "identificador" => "9914" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Case report" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/21742049/0000003700000010/v1_201810310641/S2174204918303787/v1_201810310641/en/main.pdf?idApp=UINPBA00004E&text.app=https://revportcardiol.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2174204918303787?idApp=UINPBA00004E" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 8 | 5 | 13 |
| 2024 October | 38 | 24 | 62 |
| 2024 September | 54 | 23 | 77 |
| 2024 August | 44 | 22 | 66 |
| 2024 July | 40 | 30 | 70 |
| 2024 June | 27 | 29 | 56 |
| 2024 May | 37 | 21 | 58 |
| 2024 April | 25 | 23 | 48 |
| 2024 March | 28 | 23 | 51 |
| 2024 February | 35 | 22 | 57 |
| 2024 January | 34 | 23 | 57 |
| 2023 December | 31 | 30 | 61 |
| 2023 November | 38 | 21 | 59 |
| 2023 October | 20 | 14 | 34 |
| 2023 September | 27 | 18 | 45 |
| 2023 August | 22 | 21 | 43 |
| 2023 July | 16 | 7 | 23 |
| 2023 June | 31 | 7 | 38 |
| 2023 May | 29 | 28 | 57 |
| 2023 April | 34 | 3 | 37 |
| 2023 March | 37 | 16 | 53 |
| 2023 February | 27 | 15 | 42 |
| 2023 January | 37 | 20 | 57 |
| 2022 December | 37 | 22 | 59 |
| 2022 November | 41 | 21 | 62 |
| 2022 October | 38 | 26 | 64 |
| 2022 September | 20 | 25 | 45 |
| 2022 August | 24 | 28 | 52 |
| 2022 July | 34 | 41 | 75 |
| 2022 June | 28 | 33 | 61 |
| 2022 May | 34 | 32 | 66 |
| 2022 April | 31 | 35 | 66 |
| 2022 March | 31 | 45 | 76 |
| 2022 February | 33 | 30 | 63 |
| 2022 January | 21 | 28 | 49 |
| 2021 December | 20 | 30 | 50 |
| 2021 November | 30 | 40 | 70 |
| 2021 October | 51 | 52 | 103 |
| 2021 September | 36 | 32 | 68 |
| 2021 August | 23 | 31 | 54 |
| 2021 July | 31 | 27 | 58 |
| 2021 June | 28 | 13 | 41 |
| 2021 May | 34 | 34 | 68 |
| 2021 April | 27 | 31 | 58 |
| 2021 March | 51 | 24 | 75 |
| 2021 February | 20 | 20 | 40 |
| 2021 January | 22 | 20 | 42 |
| 2020 December | 24 | 4 | 28 |
| 2020 November | 16 | 18 | 34 |
| 2020 October | 14 | 7 | 21 |
| 2020 September | 16 | 11 | 27 |
| 2020 August | 20 | 13 | 33 |
| 2020 July | 31 | 17 | 48 |
| 2020 June | 19 | 7 | 26 |
| 2020 May | 26 | 3 | 29 |
| 2020 April | 20 | 7 | 27 |
| 2020 March | 18 | 11 | 29 |
| 2020 February | 98 | 12 | 110 |
| 2020 January | 10 | 4 | 14 |
| 2019 December | 13 | 13 | 26 |
| 2019 November | 17 | 7 | 24 |
| 2019 October | 16 | 4 | 20 |
| 2019 September | 36 | 7 | 43 |
| 2019 August | 15 | 6 | 21 |
| 2019 July | 17 | 11 | 28 |
| 2019 June | 16 | 10 | 26 |
| 2019 May | 16 | 4 | 20 |
| 2019 April | 13 | 18 | 31 |
| 2019 March | 11 | 13 | 24 |
| 2019 February | 17 | 8 | 25 |
| 2019 January | 14 | 11 | 25 |
| 2018 December | 17 | 24 | 41 |
| 2018 November | 47 | 34 | 81 |
| 2018 October | 4 | 2 | 6 |
Show all
