严重钙化病变的pci治疗-王海昌.ppt

15/6/20241XijingHospitalApplication of Percutaneous Coronary Intervention for Severe Calcification Lesions 严重钙化病变的严重钙化病变的PCI治疗治疗王海昌王海昌第四军医大学西京医院心脏内科第四军医大学西京医院心脏内科 陕西西安陕西西安25/6/20242XijingHospital35/6/20243XijingHospitalCulprit and Healed Plaques in a Coronary BifurcationCoronary artery disease:Diffuse disease with a variable mix of stable,vunerable and culprit plaques Fuster V,etal.JACC,2005:46:937-95445/6/20244XijingHospitalEpidemiology o由动脉粥样硬化导致，非退行性变o检出率存在显著的性别差异（女：男=1：2）o冠状动脉钙化计分随年龄增加呈增加趋势 o冠心病危险因素与冠状动脉钙化密切相关 oBakdash 等报告非脂质性冠状动脉危险因素的数目与冠状动脉钙化沉积有关 55/6/20245XijingHospital29%ofmenand15%ofwomenwhohadnocardiovascularsymptomsandexhibitednoothercommonriskfactors,hadextensivecoronaryarterycalcification.European Heart Journal 25:4855,2004 65/6/20246XijingHospitalq Angiogramcannotdetectcalcifications(CAG)qUltrafastcomputedtomography(CT scanning)qcanmeasurearterialcalcification(noninvasive)qIntravascularUltrasound（IVUS）q OpticalCoherenceTomography(OCT)Diagnosis Methods 75/6/20247XijingHospital85/6/20248XijingHospital95/6/20249XijingHospitalCalcifiedcoronaryplaquesimagedinvivobyopticalcoherencetomography(OCT)andintravascularultrasound(IVUS)OCTOCTIVUSIVUS105/6/202410XijingHospitalNon-invasive Quantification for Calcified Lesions by CT Scan115/6/202411XijingHospital125/6/202412XijingHospital135/6/202413XijingHospital“中重度钙化（B型）病变是导致冠状动脉球囊成形术（PTCA）手术失败和血管急性闭塞的主要危险因素”1988年ACC/AHA心血管诊治技术评价的报告145/6/202414XijingHospital钙化病变介入治疗q 单纯球囊扩张（PTCA）q 成功率低（74），夹层率高，急性血管闭塞率高q 球囊扩张支架术 可改善球囊扩张后的效果，提高成功率 严重钙化病变，单凭高压力植入支架，并发症高、再狭窄率高155/6/202415XijingHospital钙化病变单纯PTCA的局限性q 即刻效果 病变不能扩展和发生弹性回缩q 再狭窄 多数研究没有显示钙化病变和PTCA后再狭窄之间的 关系165/6/202416XijingHospitalCase1(Balloon+DES)CAG175/6/202417XijingHospitalCase1(Balloon+DES)COSTLY!p3.5hrsOperationtimepLongX-RayExposurep6Balloonsp3GuideWirep3DrugElutionStents185/6/202418XijingHospitalCase1(Balloon+DES)Pre-O Final CAG195/6/202419XijingHospital球囊成形术（PTCA）q 冠脉夹层1.发生率高，程度重。2.部位在钙化与非钙化斑块的移行处，与球囊扩张过程中所产生的不均匀的剪切力有关3.发生率从旋磨后的22增加到辅以球囊扩张后的77，夹层分离的部位也从钙化斑块的内（旋磨后）移至钙化斑块的外（PTCA后）4.高压扩张，增加了球囊破裂和夹层分离的危险。205/6/202420XijingHospitalInitialReaction:Fear215/6/202421XijingHospitalAtherectomyremovetheplaqueitself,cuttingthesoftplaquefromtheobstructionsitedepositingitinacapsulewhichisthenwithdrawn.Atherocathcourtesy Guidant225/6/202422XijingHospitalLaserSomecathetershavealsobeenfittedwithspeciallaserswhichcanphoto-dissolvethetissueobstructingthearteries.Laser catheter准分子激光冠脉成形术（ELCA）有报道称手术成功率较高。使钙化破裂而不是清除，对一些不能扩张的病变是有效的。术后再狭窄率较高为4050。已经被旋磨取代235/6/202423XijingHospitalRotablator:rotational atherectomy catheterRotablatorolive-shapeddiamondburrrotatesatextremelyhighspeed245/6/202424XijingHospitalRotablatorSyetem驱动杆驱动杆导丝导丝钻石涂层磨头钻石涂层磨头1.25 mm-2.5 mm(0.25 mm increments)鞘管鞘管 4.3 french O.D.255/6/202425XijingHospitalRotablation is recommended for fibrotic or heavily calcified lesions that can be wired but not crossed by a balloon or adequately dilated before planned stenting.One must know how to manage the complications inherent to rotablation.AHA/ACC/FDA PCI Guideline265/6/202426XijingHospital钙化病变的分类q 内膜面钙化 严重者影响球囊、支架的充分扩张，需要旋磨q 外膜或斑块基底部钙化 造影显示明显，对PCI影响不大，不需旋磨275/6/202427XijingHospitalDES时代钙化病变治疗的要点q 钙化病变预扩张q 支架完全覆盖病变q 支架释放压16-18ATMq 后扩张q 血管内超声 285/6/202428XijingHospital STRTAS(Study To Determine Rotablator and Transluminal Angioplasty Strategy)初步结果显示，采用更大的磨头和较长的旋磨时间进行强烈的消蚀与更保守的消蚀方法相比，并没有改善即刻和远期效果。旋磨支架（rotastent）能得到最大的管腔和最小的残余狭窄。295/6/202429XijingHospital钙化病变介入治疗的难点（I）q 单纯依靠冠脉造影评价钙化程度欠准确q 植入支架后的再狭窄率高q 旋磨术适于内膜弥漫钙化病变，利于支架充分 植入，长期疗效更好，“无复流现象”增加q 斑块切除术（DCA、TEC、ELCA）对钙化病变帮助较小305/6/202430XijingHospital钙化病变介入治疗的难点（II）q 直接支架植入应当慎重 支架通过困难，易造成支架脱落率增加 如用高压力（16atm）仍未使支架充分扩张者，采用更高压力（20atm），仍可能不会达到满意 的支架扩张 支架不能充分扩张，亚急性血栓发生率增加 内膜夹层、撕裂率增加 球囊破裂、血管破裂、心包填塞增加315/6/202431XijingHospitalCase2：Severe Calcification and Balloon Suboptimal Dilation lead to Acute Stent ThrombosisMale，57yrsSmoking 30yrs，Chest pain 3yrs，Rest ECG：V1-V3 lead ST segment depression0.1mvCadiac Triponin T(-)Severe Calcification Baloon dilation Stenting 325/6/202432XijingHospitalCase2：Severe Calcification and Baloon Suboptimal Dilation lead to Acute Stent Thrombosis4 days later!335/6/202433XijingHospitalFemale，76yrsExertionalchestpain8yrs,recurrent10daysEF:40%RCA1:50，RCA3:75 LAD6：75,7段段90 with severe calcification，8:50，9:50；LCX13:100,14:25%,15:50Case3：Rotational Atherectomy for Severe Calcification 345/6/202434XijingHospitalCutting Balloon:2.5*10 (16ATM,20)Post dilate balloon:2.513 (18ATM,12)Case3：Rotational Atherectomy for Severe Calcification 355/6/202435XijingHospitalGuiding：6F EBU3.5Guide Wire：Stablizer/PT2MSBur:1.5mmRotor rate：160000 rpmCase3：Rotational Atherectomy for Severe Calcification 365/6/202436XijingHospital2.524TAXUS(10ATM,8)2.7528TAXUS(12ATM,7)Final CAG Stenting 375/6/202437XijingHospital钙化病变的器械选择（I）导引导管：强支撑力 导引导丝：亲水涂层导丝，支撑力 好，采用微导管交换钢丝 球囊和支架通过性好 385/6/202438XijingHospital钙化病变的器械选择（II）q 支架建议选择设计有桥连接的支架 设计良好的管状支架，闭环系统、辐射力好、金属覆 盖率好。能够使支架更合理扩张、血栓率低、再狭窄 率低q旋磨头 依据血管直径，从小到大更换，最大旋磨头应 选择直径小于血管直径的75。395/6/202439XijingHospital钙化病变的操作要点（I）预扩张：非常重要！支架往往不能直接通过病变；支架直接植入常会 导致支架不能充分扩张 球囊扩张 选择比血管直径小0.5mm以上的半顺应性、耐高压 球囊，扩张压在8atm以上，逐渐增加压力，直至 球囊切迹消失切割球囊的使用 小样本研究显示，明显钙化病变的切割球囊治疗安 全有效405/6/202440XijingHospital132patientsatleastonemoderate-severelycalcifiedlesiononfluoroscopyoRotablation/DESvsDESaloneoPrimaryendpoint8monthbinaryangiographicrestenosisoSecondaryendpointsproceduralsuccess/MACE;acute/subacute/latestentthrombosisROCCSTAR Trial(RandomisationOfCalcifiedCoronaryStenosestoTAxusstentingwithorwithoutRotationalatherectomy)415/6/202441XijingHospitalObservationstodatereimpactofRotablationonproceduraloutcomeincalcifiedlesions1.Inarrivingat56ptsinDESalonelimb,of64ptsintendedforthislimb,8(12.5%)unabletopredilatefully(placedinROCCSTARRotablatorregistry)2.Subacutestentthrombosis2/56(3.6%)inDESalonelimb(bothinsmallvessels)vs0/57inRoto/DESlimb425/6/202442XijingHospital435/6/202443XijingHospital445/6/202444XijingHospital455/6/202445XijingHospitalpRotationalatherectomyexpandsthepotentialforsafeandeffectivepercutaneoustreatmentpThedeviceisindicatedparticularlyinhighriskptsturneddownforCABG(calcification).pTheremayalsobelongertermbenefitsinreducingrestenosisimprovedstentdeployment,reducedadventitialplaque,reducedplaqueshift.465/6/202446XijingHospitalTHANK YOU A healthy smile may promote a healthy heart!