冠脈分叉病變介入技巧

1、分叉病變介入技巧分叉病變介入技巧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 P

2、roximalSBn一個(gè)好還是兩個(gè)好？一個(gè)好還是兩個(gè)好？n如果選個(gè)，應(yīng)該采取何種策略如果選個(gè)，應(yīng)該采取何種策略 ?策略選擇的根據(jù)策略選擇的根據(jù)n 簡單化簡單化 vs 復(fù)雜化復(fù)雜化n 循證結(jié)果循證結(jié)果 vs 個(gè)人選擇個(gè)人選擇n 并發(fā)癥率并發(fā)癥率 (especially MI / thrombosis)分叉病變介入治療分叉病變介入治療- 關(guān)注熱點(diǎn)關(guān)注熱點(diǎn) Provisional Stenting Strategyn If 2nd stent is needed for side branch following main vessel stentingn Modified T-stentingn

3、Reverse crushingn Culotte stenting分支血管的保護(hù)與放置支架分支血管的保護(hù)與放置支架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 根據(jù)以下情況實(shí)施分支血管保護(hù)和支架植根據(jù)以下情況實(shí)施分支血管保護(hù)和支架植入入 分支血管大小與分布區(qū)域分支血管大小與分布區(qū)域 分支血管開口病變與病變程度分支血管開口病變與病變程度 分支與主支成角程度分支與主支成角程度Side branch closure after PCISide-branch may be compromised following main vessel stentingPre-treatmentAft

4、er 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

5、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

6、stenting techniquenThe skirt techniqueThe V stenting techniqueThe simultaneous kissing stents techniqueThe V stenting and the simultaneous kissing stenting techniquen適合于分叉病變位于接近開口的血管近適合于分叉病變位于接近開口的血管近端，例如位于左主干的分叉病變，并且端，例如位于左主干的分叉病變，并且左主干短或無病變。理想夾角左主干短或無病變。理想夾角90。nV支架也適合于其他部位的分叉病變，支架也適合于其他部位的分叉病變，近段無

7、病變或無須支架。近段無病變或無須支架。 The V stenting and the simultaneous kissing stenting techniquen優(yōu)點(diǎn)優(yōu)點(diǎn):保證不會(huì)丟失分支。保證不會(huì)丟失分支。 對吻技術(shù)時(shí)無須對吻技術(shù)時(shí)無須 re-cross any stent. The V stenting and the simultaneous kissing stenting techniquen缺點(diǎn)缺點(diǎn):雙支架近端定位較困難；雙支架近端定位較困難；不可避免造成其中一個(gè)支架偏心，往往引起不可避免造成其中一個(gè)支架偏心，往往引起 a gap。The T stenting techniqu

8、eThe modified T stenting techniqueThe T and modified T stenting techniquen優(yōu)點(diǎn)優(yōu)點(diǎn):較較crush 技術(shù)容易完成。技術(shù)容易完成。缺點(diǎn)缺點(diǎn):大多數(shù)情況下，分支開口不能完全覆蓋。大多數(shù)情況下，分支開口不能完全覆蓋。Effects of the T stenting techniqueRESEARCH bifurcation subgroupRR of different techniquesThe high restenosis rate of T stenting technique may be related to t

9、he 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:100nProvisi

10、onal T stenting: 100n32% subjects received Cypher stent and RVD was 3.32mm。Provisional T stentingn優(yōu)點(diǎn)優(yōu)點(diǎn):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

11、 4a), most subjects only need one stent implantation。Provisional T stentingThe crush techniqueThe crush techniquen優(yōu)點(diǎn)優(yōu)點(diǎn):可以保證兩條分支的立刻開通可以保證兩條分支的立刻開通,這點(diǎn)對保護(hù)功能上重要的這點(diǎn)對保護(hù)功能上重要的分支非常重要。分支非常重要?？梢酝耆采w分支開口?？梢酝耆采w分支開口。n缺點(diǎn)缺點(diǎn):由于有多層支架金屬，導(dǎo)絲和球囊再次通過較困難，操作由于有多層支架金屬，導(dǎo)絲和球囊再次通過較困難，操作復(fù)雜。復(fù)雜。Ge et al. JACC 2005; 46: 613Long t

12、erm 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主要用于臨時(shí)分支支架植入主要用于臨時(shí)分支支架植入provisional SB stenting. The reverse crush

13、or internal crush technique 優(yōu)點(diǎn)優(yōu)點(diǎn):可以保證兩條分支的立刻開通，可以保證兩條分支的立刻開通，6F guiding catheter可以完成操作?？梢酝瓿刹僮?。 缺點(diǎn)缺點(diǎn):由于有多層支架金屬，導(dǎo)絲和球囊再次通過較困難，由于有多層支架金屬，導(dǎo)絲和球囊再次通過較困難，操作復(fù)雜。操作復(fù)雜。The step crush techniqueCase: The step crush techniqueFirst kissingSecond kissingFinal resultThe step crush techniquen優(yōu)點(diǎn)優(yōu)點(diǎn):6F guiding catheter可以

14、完成操作，特別適合于橈動(dòng)可以完成操作，特別適合于橈動(dòng)脈經(jīng)路，第二次導(dǎo)絲和球囊再次通過較容易成功。脈經(jīng)路，第二次導(dǎo)絲和球囊再次通過較容易成功。 缺點(diǎn)缺點(diǎn):同同 the standard crush technique. The inverted crush techniqueThe inverted crush techniquen適用于分支管徑不小于主支的情況。適用于分支管徑不小于主支的情況。n分支支架擠壓分支支架擠壓crush主支支架主支支架。n缺點(diǎn)缺點(diǎn):同同 the standard crush technique. Restenosis in MV = 12.2%Restenosis i

15、n SB = 2%The culottes stenting techniqueThe culottes stenting techniquen優(yōu)點(diǎn)優(yōu)點(diǎn):適合于任何角度的分叉病變，并提供完美的適合于任何角度的分叉病變，并提供完美的分支開口覆蓋。分支開口覆蓋。n缺點(diǎn)缺點(diǎn):分叉病變近段雙層支架重疊，金屬密度高。分叉病變近段雙層支架重疊，金屬密度高。Individual end-point at 6 months The Y stenting techniqueThe skirt techniqueThe Y stenting technique and The skirt techniquen優(yōu)點(diǎn)

16、優(yōu)點(diǎn):這是最后一種治療分叉病變的方法，適用于非常這是最后一種治療分叉病變的方法，適用于非常復(fù)雜的分叉病變并要求保證導(dǎo)絲進(jìn)入兩分支。復(fù)雜的分叉病變并要求保證導(dǎo)絲進(jìn)入兩分支。n缺點(diǎn)缺點(diǎn):n近端支架釋放系統(tǒng)需要改良，手工將支架捻在雙近端支架釋放系統(tǒng)需要改良，手工將支架捻在雙球囊上。應(yīng)用球囊上。應(yīng)用DES易破壞易破壞polymer 。n近端支架很難完全連接遠(yuǎn)端雙支架。近端支架很難完全連接遠(yuǎn)端雙支架。n采用采用Y 支架技術(shù)時(shí)，多數(shù)術(shù)者將分支導(dǎo)絲回撤并支架技術(shù)時(shí)，多數(shù)術(shù)者將分支導(dǎo)絲回撤并放入主支，這時(shí)釋放近端支架可以更好放入主支，這時(shí)釋放近端支架可以更好連接遠(yuǎn)端連接遠(yuǎn)端支架支架The Y stenting

17、 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 techniq