分叉病变介入治疗(我的课件)

,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,*,*,分叉病变介入治疗,天津市第三中心医院心脏中心,刘迎午,Content,Definition of bifurcation lesion,Classification of bifurcation lesion,Strategy of bifurcation-one stent or two stents,Specific stent for bifurcation,Clinical cases,definition,累及到冠状动脉分叉的病变,冠状动脉病变中分叉病变较为常见，约占经皮冠状动脉介入治疗(pereutaneous coronary intervention，PCI)的1520,分叉病变的解剖结构(斑块负荷、斑块位置、血管角度、血管直径、分叉位置)千变万化而治疗过程中解剖结构也会随时改变(斑块迁移、血管夹层),所以无两个完全一致的分叉病变，更无一种可适用于所有分叉病变的手术方法,Classification,Classification of bifurcation lesions according to plaque burden,A:Duke,B:Sanborn,C:Safian,D:Lefevre,Medina A. et al. Rev Esp Cardiol. 2006; 59: 183-4,A New Classification of Coronary Bifurcation Lesions,- Medina Classification,1, 1, 1,1 , 1, 0,1, 0 , 1,0, 1, 1,1, 0, 0,0, 1, 0,0, 0, 1,MB,Distal,MB,Proximal,SB,一个好还是两个好？,如果选个，应该采取何种策略 ?,策略选择的根据,简单化 vs 复杂化,循证结果 vs 个人选择,并发症率 (especially MI / thrombosis),分叉病变介入治疗- 关注热点,Stenting for bifurcation lesions in 2007,主支放支架，分支临时决定,Stenting the main vessel with,provisional stenting of the side branch,Provisional Stenting Strategy,If 2,nd,stent is needed for side branch following main vessel stenting,Modified T-stenting,Reverse crushing,Culotte stenting,分支血管的保护与放置支架,并非所有分支血管同等重要!,根据以下情况实施分支血管保护和支架植入,分支血管大小与分布区域,分支血管开口病变与病变程度,分支与主支成角程度,Side branch closure after PCI,Side-branch may be compromised following main vessel stenting,Pre-treatment,After stenting,Plaque shifting,(“Snow-plow”),Ostial spasm,or,Side-branch compromise by stent material,Dissection of plaque at origin of side-branch,Dissection flap at main artery obstructing origin of side-branch,At times, the side branch could be compromised by thrombus too,Different techniques of two stents by intention to treat bifurcation lesions,The V stenting technique,The simultaneous kissing stents technique,The T stenting and modified T stenting technique,The crush technique(The reverse crush technique/The step crush technique/The inverted crush technique),The culottes stenting technique,The Y stenting technique,The skirt technique,The V stenting technique,The simultaneous kissing stents technique,The V stenting and the simultaneous kissing stenting technique,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，并且左主干短或无病变。理想夹角90。,V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。,The V stenting and the simultaneous kissing stenting technique,优点:,保证不会丢失分支。,对吻技术时无须,re-cross any stent.,The V stenting and the simultaneous kissing stenting technique,缺点:,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 a gap。,The T stenting technique,The modified T stenting technique,The T and modified T stenting technique,优点:,较crush 技术容易完成。,缺点:,大多数情况下，分支开口不能完全覆盖。,Colombo et al Circulation 2004; 109:1244-1249,* High cross-over rate from Stent + Balloon to,Stent + Stent group (22/43, 51%),Cypher Bifurcation Stenting,( T-stenting ),Effects of the T stenting technique,RESEARCH bifurcation subgroup,RR of different techniques,The 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, 91:115-8,Effects of the T stenting technique,V stenting vs T stenting,Sharma et al.,V stenting:100,Provisional T stenting: 100,32% subjects received Cypher stent and RVD was 3.32mm。,Provisional T stenting,优点:,Higher procedural success rate,Lower expense,Lower complications,Lower re-PCI,7mons TLR 15%,。,Lefevre,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 stenting,The crush technique,The crush technique,优点:,可以保证两条分支的立刻开通,这点对保护功能上重要的分支非常重要。,可以完全覆盖分支开口。,缺点:,由于有多层支架金属，导丝和球囊再次通过较困难，操作复杂。,Ge et al. JACC 2005; 46: 613,Long term outcome of “Crush”Stenting technique,6 mons RR Colombo et al.,The crush technique,The reverse crush or internal crush technique,The reverse crush or internal crush technique,主要用于临时分支支架植入provisional SB stenting.,The reverse crush or internal crush technique,优点:,可以保证两条分支的立刻开通，6F guiding catheter可以完成操作。,缺点:,由于有多层支架金属，导丝和球囊再次通过较困难，操作复杂。,The step crush technique,double kissing,Case: The step crush technique,First kissing,Second kissing,Final result,The step crush technique,优点:,6F guiding catheter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。,缺点:,同 the standard crush technique.,The inverted crush technique,The inverted crush technique,适用于分支管径不小于主支的情况。,分支支架挤压crush主支支架,。,缺点:,同 the standard crush technique.,Restenosis in MV = 12.2%,Restenosis in SB = 2%,Galassi et al. Cath 69: 976-83,The culottes stenting technique,The culottes stenting technique,优点:,适合于任何角度的分叉病变，并提供完美的分支开口覆盖。,缺点:,分叉病变近段双层支架重叠，金属密度高。,Nordic Bifurcation Study II,- The Nordic Stent Technique Study,: Crush vs Culotte stenting,Nordic Bifurcation Study II,- The Nordic Stent Technique Study,: Crush vs Culotte stenting,Individual end-point at 6 months,The Y stenting technique,The skirt technique,The Y stenting technique and The skirt technique,优点:,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。,缺点:,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DES易破坏polymer 。,近端支架很难完全连接远端双支架。,采用Y 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,连接远端支架,The Y stenting technique,77 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;82:7A50S,Classification of bifurcation lesions according to plaque burden,A:Duke,B:Sanborn,C:Safian,D:Lefevre,The V stenting technique,The simultaneous kissing stents technique,The T stenting and modified T stenting technique,The crush technique(The reverse crush technique/The step crush technique/The inverted crush technique),The culottes stenting technique,Each lesion must be approached therapeutically in the context of its own anatomy.,Thanks for your attention!,