冠脉严重钙化病变的处理.ppt

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,*,*,*,冠脉严重钙化病变的处理,广东省心血管病研究所,陈纪言,Calcification in 1155 lesions:,QCA:,32%with Ca+,IVUS:,73%with Ca+,WHC 1995,钙化性病变的发生率,WHC 1995,How often are lesions calcified?,严重钙化性病变的介入治疗,严重钙化性病变的介入治疗,-并发症高,-成功率低,-支架膨胀不全/贴壁不良,严重钙化病变难以扩张,常常需要预处理,Restenosis after Stenting Calcified Vessels.Mosseri,Satler,Pichard,Waksman.CV Rad Medic;6:147-153,662 calcified lesions had IVUS guided stenting(BMS)and 6 months f/u,严重钙化病变的介入,钙化病变识别及潜在风险,严重钙化性病变增长PCI并发症的风险.,严重钙化性病变会影响支架的膨胀/贴壁.,要清晰认识到严重钙化病变给介入手术也许带来的潜在风险.,IVUS 对判断钙化的严重程度及介入方略制定提供有用的根据.,螺旋CT对钙化程度的判断有协助.,严重钙化性病变的识别,冠脉造影,IVUS,螺旋CT,80,Superficial,Deep,Deep,Calcium is,quantified,by measuring the“arc”it encompasses,Calcium is,classified,by its location within the plaque,Superficial calcium is closer to the lumen than to the adventitia,Deep calcium is closer to the adventitia than to the lumen,The CardiovascularResearch Foundation,Lenox Hill Heart and VascularInstitute of New York,Calcium,Bright echos(brighter than the adventitia),Obstructs the penetration of ultrasound(acoustic shadowing),Only the leading edge is detected and thickness cannot be determined,Calcium,Behind calcium:Acoustic Shadow,非环,形,钙化,环形钙化,螺旋CT,严重钙化病变的介入,LAD 简朴病变,Rota and DES,病例1,导丝与指导导管的选择,钙化病变复杂,管腔迂曲,导丝及介入器材通过困难,阻力较大;,使用强支撑力指导导管;,(XB,EBU,AL1,AL2,),使用特殊导丝,如亲水涂层导丝,(Whisper,PT2,Pilot,Hypercoat Runthrough),球囊预扩张与否需要?,严重钙化病变会导致支架膨胀不全,增长血栓及再狭窄的风险,因此不适宜直接支架;,支架通过病变困难,损坏药膜,支架脱载,手术失败;,因此,预扩张是必须的;,如预扩张存在腰征,改用非顺应性球囊.,球囊预处理效果不好时的处理,球囊预扩张后也许仍存在的问题,-球囊仍存腰征,-支架不能通过,切割球囊,Roto,非(或低)顺应性球囊作用机制,球囊材料不一样于一般预扩张球囊,球囊压力增长直径增长小,对血管的扩张力不小于一般预扩张球囊,比一般球囊抗穿刺能力强,局限性:,通过病变的能力弱,球囊回裹能力差,注意:不提议用一般预扩张球囊高压扩张钙化病变,在高压的状况下,假如忽然扩开血管,因此时球囊直径很大,极易引起血管的扯破,以至穿孔,导致严重的并发症,Vessel Biomechanics,Cutting Balloon,Vessel Biomechanics Cutting Balloon,切割球囊治疗钙化病变的适应症,表浅钙化,钙化弧180度的钙化,旋磨术的功能,斑块被磨成小的颗粒称为微颗粒,微颗粒的大小:不不小于5微米（比红细胞小),微颗粒被人体吞噬细胞系统降解,D Bowles,差异切割,弹性组织,非弹性组织,D Bowles,旋磨的长处,血管壁的延伸使弹性回缩减到至少,消除血管的气压性创伤,消除纤维化及钙化斑块,形成一种光滑的内腔通道,合适的旋磨治疗,可以使:,D Bowles,血管截面观,经典的血管成形术所导致的血管损伤,经典的旋磨成形术所形成的极小血管损伤,D Bowles,冠脉CTA,Sep,Cal,Cal,女，80岁,T2DM 20,+,年、HTN 20,+,年,稳定型心绞痛,CTA：三支冠脉病变,LAD,球囊扩张后,FireStar 2.0 22 atm,球囊破裂,旋磨,1.5 mm 165000rpm,Dissection,LCx,Sep,旋磨后,Cal,支架,FireBird 2.5*33,FireBird 3.0*23,LM bifurcation,最终成果,Sep,LCx,stent,myocardial bridge,病例2,女性,86岁,UA 伴HF,EF38%,COPD,TVD,DES的效果,Restenosis in Calcified Lesions.Taxus V.Braden et al.AHA,Non Calcified Calcified,Non Calcified Calcified,In Segment Restenosis IVUS Intimal Hyperplasia,376 lesions with moderate or severe calcification,306 Lesions with Moderate to Severe Calcificationin Vessels 3 mm,WHC 1996,Rota,Stent,Rot+St,p,refer ves,3.16,3.36,3.35,0.0001,final mld,2.08,2.82,3.27,0.0001,final DS,34%,13%,4%,0.0001,TLR,32%,25%,12%,0.02,150例持续性严重钙化病人,小 结,注意识别钙化病变,高压球囊,旋磨装置进行病变预处理,应用合适的技巧可提高治疗成功率,减少并发症,Thank you!,