CTO病变介入治疗技巧PPT学习教案

会计学1CTO病变介入治疗技巧病变介入治疗技巧Multi-vessel disease with CTO第1页/共70页30%70%Patients with TotalOcclusionsPatients withoutTotal OcclusionsSource: Cardiac Data Resources, The BLG Group30% of patients have one or more total occlusions第2页/共70页第3页/共70页2,007 Consecutive CTO patients June 1980 December 1999 distinct 10-year survival advantage for successful CTO treatment compared to failed CTO treatment.(73.5% vs 65.1%, p=0.001) Suero et. al - JACC August 2001 第4页/共70页“At one year follow up, patients with successful PCI of a CTO had a significantly better clinical outcome than those whose PCI was unsuccessfulOlivari, et al., JACC May 21, 2003 At 12 months, patients with a successful CTO procedure experienced: Lower incidence of cardiac deaths or MIs (1.05% vs 7.23%, p=0.005)Reduced need for CABG (2.45% vs 15.7%, p3个月对成功不利2. 闭塞段血管长度15mm 对成功不利3. 闭塞近端管状或鼠尾状VS齐头状齐头状使导丝侧滑对成功不利4. 血管闭塞处存在侧支血管对成功不利5. 桥侧支血管的形成对成功不利第11页/共70页利于或不利于成功的CTO病变特征第12页/共70页第13页/共70页对角支LAD第14页/共70页闭塞段第15页/共70页闭塞处分支严重扭曲闭塞处第16页/共70页第17页/共70页对角支LAD侧支循环LAD闭塞处第18页/共70页分支主干闭塞处？第19页/共70页前降支侧支循环显影第20页/共70页第21页/共70页桥侧支血管第22页/共70页功能性闭塞段第23页/共70页第24页/共70页第25页/共70页Neo channels can lead through the stenosis or can connect with vasa-vasorum. Connections with vasa-vasorum more likely result in sub-intimal dissection or wire exit第26页/共70页对病变的了解不全面或技术没有完全掌握就可能给患者带来风险第27页/共70页第28页/共70页Amplatz(AL 1.0)JR 4.0指引导管时1.5mm球囊不能通过第29页/共70页第30页/共70页EBU 3.5PT2 LS1.5mm Over The Wire 球囊第31页/共70页LAD闭塞处LCX第32页/共70页Hydrophilic (slippery) wire tip has difficulty engaging entry point dimpleLow lubricity (spring coil) wireTip can more easily engage entry point dimple第33页/共70页EBU 3.5CROSS-IT 200第34页/共70页HydrophylicChoice-PT(BSC)PT SeriesStiff SpringMiracle Bros (Abbott)Cross-It (Guidant)Stiff HydrophylicShinobi (Cordis)PT Interm. (BSC)第35页/共70页CTO介入治疗器械决定操作是否成功第36页/共70页第37页/共70页第38页/共70页当第一根导丝进入夹层时：平行导丝技术第39页/共70页导丝在血管腔外第40页/共70页第二根导丝进入真腔第41页/共70页2006-08-27 北京首都机场平行导丝技术要求的技巧1. 远端管腔显影良好2. 避免两条导丝缠绕3. 建议使用头部性能好的导丝第42页/共70页第43页/共70页第44页/共70页球囊PT2-MS导丝（经左冠）BMW（经右冠）第45页/共70页对角支前降支第46页/共70页第47页/共70页第48页/共70页闭塞病变扩张边支开口技术 第49页/共70页If guide wire consistently goes into the side branch - use a compliant balloon at low pressure to better direct guide wire第50页/共70页第51页/共70页第52页/共70页坚持、坚持、再坚持！但下列情况时STOP出现并发症（大或小）造影剂用量过多（5001000CC）曝光时间过长（60min）手术时间过长（2-3小时)第53页/共70页第54页/共70页第55页/共70页第56页/共70页Clinical Event (%)204P0.001248228194320P=0.003P=0.009P=0.001P=NSP=NS0第57页/共70页4136117%73%81%6 Month Angiographic Binary Restenosis Relative Risk Reduction第58页/共70页Note: * Stented segment including proximal and distal 5 mm4111367134*p0.0001p0.001p30-180 days01 (1%)p=ns第60页/共70页第61页/共70页第62页/共70页第63页/共70页CTO病变介入治疗并发症导丝穿出血管壁外致手术失败超声观察心包第64页/共70页心包穿刺引流管第65页/共70页有时会产生心脏壁内血肿第66页/共70页CTO病变介入治疗失败的形式导丝不能通过 不确定导丝在真腔内球囊不能通过出现并发症 无论严重与否,停止操作对患者最安全造影剂和射线达到极限第67页/共70页1. 指引导管支撑力良好2. 微导管或Over The Wire 球囊的应用3. 逐渐增加导丝的硬度4. 多角度投照5. 正确的病例选择6. 耐心和坚持CTO介入治疗技术（一）第68页/共70页CTO介入治疗技术（二）1. 双侧同时造影2. 平行导丝及see-saw 技术3. 管腔再进入（STAR)技术4. 逆向技术5. 新器械的尝试6. 一定掌握快速心包穿刺技术第69页/共70页