[基礎(chǔ)醫(yī)學(xué)]CTO病變的技巧冠心病最新進(jìn)展.ppt

慢性完全閉塞病變介入技巧和器械選擇 北京安貞醫(yī)院呂樹(shù)錚教授 慢性完全閉塞病變介入技巧和器械選擇 慢性完全閉塞病變的相關(guān)概念慢性完全閉塞病變的病理結(jié)構(gòu)和特點(diǎn)cto介入的導(dǎo)絲選擇cto病變的支架選擇 cto的定義 閉塞時(shí)間大于3個(gè)月的病變 cto病變形成時(shí)間的判斷 ami的時(shí)間癥狀加重的時(shí)間側(cè)枝循環(huán)形成的多少及側(cè)枝的直徑 cto病變長(zhǎng)度的判斷 順行顯影逆行顯影雙向造影 順行顯影 逆行顯影 cto病變的病理結(jié)構(gòu) 1 壞死脂核 膽固醇結(jié)晶及鈣化 cto病變的病理結(jié)構(gòu) 2 細(xì)胞外基質(zhì) 膠原 鈣化 cto病變的病理結(jié)構(gòu) 3 微血管 cto病變的類型 重度狹窄慢性閉塞輕中度狹窄慢性閉塞 重度狹窄慢性閉塞 主要由纖維化和鈣化的粥樣硬化斑塊組成 短閉塞段 纖維帽位于閉塞段的兩側(cè)邊緣 中間為血管壁重塑形成的組織 閉塞時(shí)間一般為3個(gè)月以上 重塑的組織中含有大量的纖維組織 長(zhǎng)閉塞段 常常有血栓的成分 閉塞段往往是纖維組織與血栓相間分布 這種病變導(dǎo)絲很難通過(guò) 成功率只有50 70 輕中度狹窄慢性閉塞 脂核 纖維組織 陳舊血栓 原有輕中度狹窄病變 班塊破裂 未及時(shí)治療 導(dǎo)致血管慢性閉塞 新的閉塞處遠(yuǎn)離原有狹窄斑塊 導(dǎo)絲注意尋找閉塞斑塊 cto病變的病理特點(diǎn) 粥樣斑塊 鈣化慢性發(fā)展融合而成 cto病變的病理特點(diǎn) 斑塊破潰形成血栓機(jī)化而成 cto介入的導(dǎo)絲選擇 導(dǎo)絲的結(jié)構(gòu) 導(dǎo)引導(dǎo)絲的性能 調(diào)節(jié)力 導(dǎo)絲尖端和中心鋼絲結(jié)構(gòu) 柔軟性 導(dǎo)絲的直徑 尖端結(jié)構(gòu)和連接段變系程度 推送力 中心鋼絲的硬度和中間變細(xì)方式 支持力 中心鋼絲的直徑和材料 處理cto病變時(shí)常用的導(dǎo)絲 超滑導(dǎo)絲 如ptgraphicintermediate pt2 shinobi crossnt whisper等coil型導(dǎo)絲 acsintermediatestandard crossit100 400 miracle3 12及conquest pro 9 12等 處理cto病變時(shí)常用導(dǎo)絲 超滑導(dǎo)絲 scimedpt2 thecombinationofapolymercoverandhydrophiliccoatingprovidesoutstandinglubricity scimedptgraphicintermediate uni bodycorewithlong smoothtaperfromsupportregiontotiphydrophilic coated polymersleeveandtipintermediatewirewithslightlystiffertipcrossingperformanceofpolymertipwithvisibilityofspringtip terumocrossnt whisper redefinespolymerwireperformance responsease grindtechnology durasteel corematerial polymercoated hydrocoatdistalsegment softtipdesignedforfrontlineuse hi torquepilot design hi torquepilot familyproductdescription designhighlights polymer tip hydrophilic core to tipwithmoderatesupport graduatedtipstiffnessinthefamily modifiedresponsease parabolicgrind durasteel corematerial singlelesionmeasurementmarker thehi torquepilot familyofguidewiresoffersachoiceofwiresthatvaryintipstiffnesstoaddressawidevarietyoflesionmorphology tipcoilsbeneaththepolymerhelpfacilitatetipshaping modifiedresponsease parabolicgrindthismodifiedresponsease designprovidesadditionalsupport excellenttorquetransmissionandin lesiontipcontrol thehi torquepilot guidewiresmaintainedtheirtipshapebetterthancompetitivewiresafterpassingthroughatortuouspathmodel thedurasteel corematerialofthehi torquepilot familyisstrongerthanconventionalstainlesssteelforimprovedcorestrengthandtipshaperetention durasteel withstandsmorepullingforcethanregular304vstainlesssteel 007 corewiresupport ptfe噴涂 近端黑色的ptfe袖套延伸至遠(yuǎn)端頭部 平的顯影線圈 shinobi shinobiplus 010 corewiresupport shinobiplus shinobi wizdom的核心鋼絲 stabilizerplus的核心鋼絲 處理cto病變時(shí)常用的導(dǎo)絲 coil型導(dǎo)絲 acsintermediate standard intermediate 中軟纏繞頭端 core to tip 錐行漸變的中間軸 standard 標(biāo)準(zhǔn)纏繞頭端 不易扭曲的推送桿 acs導(dǎo)絲 aguidetoacshi torqueguidewires crossit crossit100 400 crossit特性 smoothshaftwithfluororesincoating jointlessspringcoil propertyofasahineo sptcaguidewirefamily withtheunibodycorewhichispreciselytapereduptotheextremeend withoutadditionalribbon thushighlygoodtorqueabilityisachieved shafthasfluororesincoating whichprovideshighoperativityandgoodmatchingwithballooncatheter onepiececorewire jointlessspringcoilmadeoftwodifferentmetalsprovidesgoodtorqueabilityandexcellentslidepropertywithdevices medicalgradesiliconecoating jointlessspringcoilstructureimage soft softag141000radio opacity3cmcoil30cmdiameter0 014inchlength175cm thisisafirstchoiceguidewirewithhightorqueresponseandexcellentsteerabilitybecauseoftheuniquecoreproperty tipload0 7g intermediate mediumag142000radio opacity3cmcoil30cmdiameter0 014inchlength175cm thisisaguidewirewithagoodbalanceoftipflexibilityandsupportperformance tipload3 0g standard standardag143000radio opacity3cmcoil30cmdiameter0 014inchlength175cm improvedtipstiffnesswithouruniquecoretaperdesign tipload6 5g light lightag145000radio opacity3cmcoil20cmdiameter0 014inchlength175cm asahineo sptcaguidewireline up improvedlubricityandgoodtipshapememorywithouruniquecoredesign excellenttorqueresponse thiswirehasaflexibletipandcanbeusedasafirstchoicewireforalmostallprocedures tipload0 5g tipload3 0g miracle4 5 miraclebros4 5ag14m045radio opacity11cmcoil11cmdiameter0 014inchlength175cm tipload4 5g miracle6 miraclebros6ag14m060radio opacity11cmcoil11cmdiameter0 014inchlength175cm tipload6 0g miracle12 miraclebros12ag14m070radio opacity11cmcoil11cmdiameter0 014inchlength175cm tipload12 0g miracle3 miraclebros3ag14m050radio opacity11cmcoil11cmdiameter0 014inchlength175cm miracleseriesapplyingthestructurewhichfurtherimprovestorqueperformanceforctouse thetipparthasthestructurewhichisdifficulttobetrappedbythelesions structureofconquestpro pro12 agh143090conquestpro grandslam grandslamag141002radio opacity4cmcoil4cmdiameter0 014inchlength175cm inspiteofitsflexibletip thecoreisalsodesignedtoprovidestrongsupportwhenapproachingthetortuouslesions tipload0 7g markerwireag141010radio opacity3cmcoil30cmdiameter0 014inchlength175cm sameleveloftipstiffnessassoft ithastenmarkersstartingafter50mmfromthetiptoscalelesionsandpositiondevices tipload0 7g rinato prowaterag146000radio opacity3cmcoil20cmdiameter0 014inchlength175cm conquest confianzaag143090radio opacity20cmcoil20cmdiameter0 014inchlength175cm thiswireisdevelopedforctouse higherpenetrationabilitythanmiracles diameteroftipcoilistaperedto0 009inch 0 23mm tipload9 0g hydrophiliccoatingoverthecoilspring after3cmfromthetip newlydesignedoriginalcoreshaftgivesadequatelyhighersupportperformancethansoft improvedtorqueperformance tipload0 8g 如何選擇導(dǎo)絲 下列情況首選超滑涂層的導(dǎo)絲 1 閉塞段近端無(wú)邊支開(kāi)口 病變長(zhǎng)度 20mm 血管殘端程鼠尾狀狀 鼠尾狀 下列情況首選超滑涂層的導(dǎo)絲 2 閉塞段有彎曲的 閉塞段扭曲 下列情況首選超滑涂層的導(dǎo)絲 3 閉塞段近端及遠(yuǎn)端彎曲重的 近端過(guò)度扭曲 遠(yuǎn)端過(guò)度扭曲 下列情況首選尖端纏繞形導(dǎo)絲 1 血管殘端呈齊頭的2 閉塞段近端有分支開(kāi)口的 齊頭閉塞 下列情況首選尖端纏繞形導(dǎo)絲 3 閉塞段長(zhǎng)度 20mm4 閉塞時(shí)間 6個(gè)月 導(dǎo)絲通過(guò)閉塞段時(shí)的情況 1 導(dǎo)絲通過(guò)閉塞1 6個(gè)月內(nèi) 長(zhǎng)度 20mm沒(méi)有鈣化的病變時(shí)較順利 成功率高 導(dǎo)絲通過(guò)閉塞段時(shí)的情況 2 導(dǎo)絲通過(guò)有硬核的閉塞段時(shí) 導(dǎo)絲無(wú)法穿透斑塊 其尖端沿斑塊邊緣穿透血管壁導(dǎo)絲強(qiáng)行穿過(guò)硬斑塊核 如何判斷導(dǎo)絲是否在真腔 1 根據(jù)不同的投照角度 如何判斷導(dǎo)絲是否在真腔 2 根據(jù)導(dǎo)絲尖端的形態(tài)和走性真腔中導(dǎo)絲尖端彎形 j 存在 導(dǎo)絲可自由旋轉(zhuǎn) 可沿主支血管走形前進(jìn) 也能進(jìn)入相應(yīng)分支 并每次均能規(guī)律進(jìn)入同一走行分支 如何判斷導(dǎo)絲是否在真腔 3 通過(guò)側(cè)支循環(huán)顯示閉塞段遠(yuǎn)端造影通過(guò)逆行或順行側(cè)支顯示閉塞段遠(yuǎn)端 多角度透射觀察導(dǎo)絲是否在真腔 在導(dǎo)絲即將通過(guò)閉塞段進(jìn)入閉塞段遠(yuǎn)端血管真腔時(shí)尤應(yīng)謹(jǐn)慎 導(dǎo)絲每前進(jìn)1 2mm就應(yīng)多角度投照 調(diào)整導(dǎo)絲尖端方向 防止損傷閉塞段遠(yuǎn)端血管 造成長(zhǎng)夾層而不可修復(fù) 如何判斷導(dǎo)絲是否在真腔 4 通過(guò)otw球囊造影判斷一旦導(dǎo)絲在假腔 造影時(shí)造影劑沖擊損傷血管內(nèi)膜 形成全程長(zhǎng)夾層 導(dǎo)絲無(wú)法在進(jìn)真腔 并造成遠(yuǎn)端血管閉塞 心梗 此法很少用 導(dǎo)絲成形及操作技巧 cto病變導(dǎo)絲尖端成形半徑要小 成形半徑大 則前向力被分解 導(dǎo)絲不易前行成形半徑大 對(duì)血管壁損傷大成形半徑大 不易調(diào)整方向 閉塞段近端成角大的病變 要先將導(dǎo)絲頭端塑形成較大的角度 使其易于通過(guò)閉塞段近端的扭曲 并將微導(dǎo)管或otw球囊導(dǎo)入到病變處 再將導(dǎo)絲重新塑形成小角度或換用塑形成小角度硬導(dǎo)絲 嘗試通過(guò)病變 閉塞段較硬的病變 對(duì)于較硬的病變估計(jì)球囊不易通過(guò)者 除在導(dǎo)絲頭端塑形成角后 可在導(dǎo)絲尖端再塑形第二個(gè)小角 只適用于crossit300 400 conquestpro9 12及miracle9 12 將閉塞病變 掏 大 但導(dǎo)絲旋轉(zhuǎn)速度不能快 cto病變的支架選擇 cto病變中ptca和支架植入術(shù)比較 再狹窄發(fā)生率 cto病變中ptca和支架植入術(shù)比較 再閉塞發(fā)生率 相對(duì)于單純ptca術(shù) 金屬裸支架降低了再狹窄和再閉塞率 但仍然比較高 與金屬裸支架相比雷帕霉素藥物支架明顯降低了低或中危再狹窄風(fēng)險(xiǎn)病人的晚期管腔丟失和再狹窄率 cto中應(yīng)用cypherstent的經(jīng)驗(yàn) hoyea etal jamcollcardiol2004 43 11 1954 8 56例cypher治療gel etal eurheartj2005 26 11 1056 62 122例cypher治療nakamuras etal amjcardiol2005 95 161 6 60例cypher治療thesictostudycyphertmsirolimus elutingstentinchronictotalocclusiontheprisoniistudyprimarystentingofoccludednativecoronaryarteries sicto studydesignamulticenter prospective non randomizedstudytoassessthefeasibilityandrestenosis reocclusionratesofcoronarystentingwiththecyphertmsirolimus elutingstentinpatientswithchronictotalocclusion 25patientsweretreatedwiththecyphertmsirolimus elutingstentaftersuccessfulballoonangioplastyandivusexamination clinicalfollow upat30days 6 12 18and24months repeatangiographyandivusat6monthsfollow up sicto conclusion inthisfeasibilitystudythecyphertmsirolimus elutingstentwasveryeffectiveinthetreatmentofcto withverylowratesoftlr 0 mace 0 andtvr 8 comparedtohistoricaldatawithbarestents 30 50 thecyphertmsirolimus elutingstentsignificantlyinhibitsintimalhyperplasiainct