冠脉分叉病变介入技巧

分叉病变介入技巧分叉病变介入技巧Classification of bifurcation lesions according to plaque burdenA:DukeB:SanbornC:SafianD:LefevreMedina A.et al.Rev Esp Cardiol.2006;59:183-4A New Classification of Coronary Bifurcation Lesions-Medina Classification1,1,11,1,01,0,10,1,11,0,00,1,00,0,1MB DistalMB ProximalSBn一个好还是两个好？一个好还是两个好？n如果选个，应该采取何种策略如果选个，应该采取何种策略?策略选择的根据策略选择的根据n 简单化简单化 vs 复杂化复杂化n 循证结果循证结果 vs 个人选择个人选择n 并发症率并发症率(especially MI/thrombosis)分叉病变介入治疗分叉病变介入治疗-关注热点关注热点 Provisional Stenting Strategyn If 2nd stent is needed for side branch following main vessel stentingn Modified T-stentingn Reverse crushingn Culotte stenting分支血管的保护与放置支架分支血管的保护与放置支架n 并非所有分支血管同等重要并非所有分支血管同等重要!n 根据以下情况实施分支血管保护和支架植根据以下情况实施分支血管保护和支架植入入 分支血管大小与分布区域分支血管大小与分布区域 分支血管开口病变与病变程度分支血管开口病变与病变程度 分支与主支成角程度分支与主支成角程度Side branch closure after PCISide-branch may be compromised following main vessel stentingPre-treatmentAfter stentingPlaque shifting(“Snow-plow”)Ostial spasm orSide-branch compromise by stent materialDissection of plaque at origin of side-branchDissection flap at main artery obstructing origin of side-branchAt times,the side branch could be compromised by thrombus tooDifferent techniques of two stents by intention to treat bifurcation lesionsnThe V stenting techniquenThe simultaneous kissing stents techniquenThe T stenting and modified T stenting technique nThe crush technique(The reverse crush technique/The step crush technique/The inverted crush technique)nThe culottes stenting techniquenThe Y stenting techniquenThe skirt techniqueThe V stenting techniqueThe simultaneous kissing stents techniqueThe V stenting and the simultaneous kissing stenting techniquen适合于分叉病变位于接近开口的血管近适合于分叉病变位于接近开口的血管近端，例如位于左主干的分叉病变，并且端，例如位于左主干的分叉病变，并且左主干短或无病变。理想夹角左主干短或无病变。理想夹角90。nV支架也适合于其他部位的分叉病变，支架也适合于其他部位的分叉病变，近段无病变或无须支架。近段无病变或无须支架。The V stenting and the simultaneous kissing stenting techniquen优点优点:保证不会丢失分支。保证不会丢失分支。对吻技术时无须对吻技术时无须 re-cross any stent.The V stenting and the simultaneous kissing stenting techniquen缺点缺点:双支架近端定位较困难；双支架近端定位较困难；不可避免造成其中一个支架偏心，往往引起不可避免造成其中一个支架偏心，往往引起 a gap。The T stenting techniqueThe modified T stenting techniqueThe T and modified T stenting techniquen优点优点:较较crush 技术容易完成。技术容易完成。缺点缺点:大多数情况下，分支开口不能完全覆盖。大多数情况下，分支开口不能完全覆盖。Effects of the T stenting techniqueRESEARCH bifurcation subgroupRR of different techniquesThe high restenosis rate of T stenting technique may be related to the incomplete coverage of stenting being located at the ostium of SB.Tanabe K,Hoye A,Lemos PA,et al.Am J Cardiol,2004,91:115-8Effects of the T stenting techniqueV stenting vs T stenting1.5%19.5%2.0%5.2%0%5%10%15%20%25%ST9 mons TLRT stentingV stentingP=0.007nSharma et al.nV stenting:100nProvisional T stenting:100n32%subjects received Cypher stent and RVD was 3.32mm。Provisional T stentingn优点优点:Higher procedural success rateLower expenseLower complicationsLower re-PCIn7mons TLR 15%。nLefevre et al:Provisional T stenting is the golden standard to treat false bifurcation lesion(tpye2,3 and 4a),most subjects only need one stent implantation。Provisional T stentingThe crush techniqueThe crush techniquen优点优点:可以保证两条分支的立刻开通可以保证两条分支的立刻开通,这点对保护功能上重要的这点对保护功能上重要的分支非常重要。分支非常重要。可以完全覆盖分支开口。可以完全覆盖分支开口。n缺点缺点:由于有多层支架金属，导丝和球囊再次通过较困难，操作由于有多层支架金属，导丝和球囊再次通过较困难，操作复杂。复杂。Ge et al.JACC 2005;46:613Long term outcome of“Crush”Stenting technique 7.1%12.5%5.5%35.0%0%10%20%30%40%MBMBSBSBFKBnon-FKBP=0.116 mons RR Colombo et al.The crush techniqueThe reverse crush or internal crush techniqueThe reverse crush or internal crush techniquen主要用于临时分支支架植入主要用于临时分支支架植入provisional SB stenting.The reverse crush or internal crush technique 优点优点:可以保证两条分支的立刻开通，可以保证两条分支的立刻开通，6F guiding catheter可以完成操作。可以完成操作。缺点缺点:由于有多层支架金属，导丝和球囊再次通过较困难，由于有多层支架金属，导丝和球囊再次通过较困难，操作复杂。操作复杂。The step crush techniqueCase:The step crush techniqueFirst kissingSecond kissingFinal resultThe step crush techniquen优点优点:6F guiding catheter可以完成操作，特别适合于桡动可以完成操作，特别适合于桡动脉经路，第二次导丝和球囊再次通过较容易成功。脉经路，第二次导丝和球囊再次通过较容易成功。缺点缺点:同同 the standard crush technique.The inverted crush techniqueThe inverted crush techniquen适用于分支管径不小于主支的情况。适用于分支管径不小于主支的情况。n分支支架挤压分支支架挤压crush主支支架主支支架。n缺点缺点:同同 the standard crush technique.Restenosis in MV=12.2%Restenosis in SB=2%The culottes stenting techniqueThe culottes stenting techniquen优点优点:适合于任何角度的分叉病变，并提供完美的适合于任何角度的分叉病变，并提供完美的分支开口覆盖。分支开口覆盖。n缺点缺点:分叉病变近段双层支架重叠，金属密度高。分叉病变近段双层支架重叠，金属密度高。Individual end-point at 6 months The Y stenting techniqueThe skirt techniqueThe Y stenting technique and The skirt techniquen优点优点:这是最后一种治疗分叉病变的方法，适用于非常这是最后一种治疗分叉病变的方法，适用于非常复杂的分叉病变并要求保证导丝进入两分支。复杂的分叉病变并要求保证导丝进入两分支。n缺点缺点:n近端支架释放系统需要改良，手工将支架捻在双近端支架释放系统需要改良，手工将支架捻在双球囊上。应用球囊上。应用DES易破坏易破坏polymer。n近端支架很难完全连接远端双支架。近端支架很难完全连接远端双支架。n采用采用Y 支架技术时，多数术者将分支导丝回撤并支架技术时，多数术者将分支导丝回撤并放入主支，这时释放近端支架可以更好放入主支，这时释放近端支架可以更好连接远端连接远端支架支架The Y stenting techniquen77 case being with bifurcation lesions received the Y stenting therapy and 6 mons follow-up results:RR 36%,TLR 30%。Maillard L,Guerin L,Drieu L,et al.Am J Cardiol 1998;82:7A50SClassification of bifurcation lesions according to plaque burdenA:DukeB:SanbornC:SafianD:Lefevreo The V stenting techniqueo The simultaneous kissing stents techniqueo The T stenting and modified T stenting technique o The crush technique(The reverse crush technique/The step crush technique/The inverted crush technique)o The culottes stenting techniqueEach lesion must be approached therapeutically in the context of its own anatomy.