冠脉分叉病变不同介入治疗策略评价.ppt

冠脉分叉病变不同介入治疗冠脉分叉病变不同介入治疗冠脉分叉病变不同介入治疗冠脉分叉病变不同介入治疗策略评价策略评价策略评价策略评价阜外心血管病医院阜外心血管病医院杨伟宪杨伟宪2010-7-242010-7-24 2010-7Account for 15-20%of PCIWhy an indivdualized approach?Variations in AnatomyLeft main bifurcation diseasePlaque burden&location of plaqueAngle between MB and SBDynamic changes in anatomy during treatmentPlaque shiftDissectionNo two bifurcations are identicalAn appropriate strategy from the outset saves time and minimizes complicationBifurcation PCI分叉病变分型分叉病变分型分叉病变分型分叉病变分型Duke ClassificationSanborn ClassificationIakovou I,Ge L,Colombo A.JACC,2005;46:1446-1455.Safian ClassificationIakovou I,Ge L,Colombo A.JACC,2005;46:1446-1455.Lefevre ClassificationIakovou I,Ge L,Colombo A.JACC,2005;46:1446-1455.Medina ClassificationMedina et al.Rev Esp Cardiol.2006;59(2):183-4.分叉病变介入治疗策略分叉病变介入治疗策略单支架单支架 二个支架二个支架单个支架单个支架单个支架单个支架或或或或二二二二个支架个支架个支架个支架?A)如果分支血管的开口部位或其附近有明显的病变，其血管直径足够大，从安全性和PCI的疗效来考虑应该置入两个支架。B)在其他情况下，应置入一个支架 and then evaluate当前，大家公认和使用的分叉病变治疗策略是分支血 管 Provisional支架术。然而仍有许多分支血管其解剖结构（直径较大，病变较为弥漫）需要置入两个支架。What Type of Bifurcations are Commonly Treated?Majority(65%)are“True”bifurcations Extent of SB disease may determine strategyNon-LM Bifs treated in Milan(n=320).Extent of SB disease:0 18%10mm 36%分叉病变介入治疗技术分叉病变介入治疗技术1.分支血管通畅技术分支血管通畅技术(KIO)2.必要时置入第二个支架（必要时置入第二个支架（Provisional 2nd stent）3.双支架术双支架术分支血管通畅技术(KIO)当分支血管开口病变或弥漫性病变，并且分支血管不适合置入支架时（太细小）或者分支血管和临床症状不相关时l主支和分支血管分别放入导引钢丝l如果需要扩张主支血管l主支血管置入支架，分支血管保留导引钢丝l后扩张主支血管，分支血管保留受压的导引钢丝不要再次把导引钢丝放入分支血管或者后扩张不要再次把导引钢丝放入分支血管或者后扩张或预扩张分支血管或预扩张分支血管 Provisional 支架支架当分支血管病变程度极轻或者病变仅位于分支血管开口处并且分支血管解剖结构适合置入支架者l l主支和分支血管放入导引钢丝主支和分支血管放入导引钢丝l l扩张主支血管，必要时扩张分支血管扩张主支血管，必要时扩张分支血管l l主支血管置入支架，分支血管保留导引钢丝主支血管置入支架，分支血管保留导引钢丝l l分支血管再次放入导引钢丝，然后撤出受压的原导分支血管再次放入导引钢丝，然后撤出受压的原导 引钢丝引钢丝l l球囊对吻球囊对吻l l如果分支血管出现次佳结果则在分支血管置入支如果分支血管出现次佳结果则在分支血管置入支 架（架（T T支架术或支架术或Reverse CrushReverse Crush）保保护分支血管分支血管术前冠脉造影前降支对角支病变前降支置入支架Xience 3.0 x28mmXience 3.0 x28mm支架术后对角支POBA球囊球囊3.0 x20mm3.0 x20mm前降支对角支病变最终结果Wire both branches and pre-dilate the main and the side branch as required.Step 1:Stent the MB jailing the SB wireIf the result in SB unsatisfactory due to plaque shift or dissection and SB has to be stented,then re-cross into the SB through the MB stent strutsStep 2:The T-stenting with Protrusion Technique(TAP)as a Cross-over from the Provisional ApproachPosition stent in SB ensuring coverage of ostium with minimal protrusion into MB and place non-compliant balloon in MB stentFinal Result:Inflate the delivery balloon in the SB and the MB balloon simultaneouslyStep 3:Step 4:The T-stenting with Protrusion Technique(TAP)as a Cross-over from the Provisional Approach1:Rewire side branch and advance a balloon and dilate toward SB2:Position a stent in the SB with minimal protrusion in the MB.Leave a balloon in the MBEVALUATE RESULT:if the result is not acceptable thenAReverse Crush Stenting3:Deploy the stent in the SB and remove the wire and the balloon4:Crush the short protruding part of SB stent over the stent in MB by inflating the MB balloonBReverse Crush Stenting5:Rewire the SB and perform high pressure dilatation6:Perform final kissing balloon inflationCReverse Crush Stenting双支架术双支架术当分支血管的病变比较弥漫，不仅仅局限于分支开口部位，并且分支血管适合置入支架1.主支和分支血管放入导引钢丝主支和分支血管放入导引钢丝2.扩张主支血管，必要时扩张分支血管扩张主支血管，必要时扩张分支血管3.CrushCrush支架术或其他双支架术支架术或其他双支架术4.如果进行如果进行Crush:Crush:分支血管再次放入导引钢丝分支血管再次放入导引钢丝,对对其进行高压球囊扩张其进行高压球囊扩张5.球囊对吻扩张球囊对吻扩张CrushCrush支架术支架术标准标准Crush：7F以上以上指引导管指引导管,事先对两个支架定位，然后释事先对两个支架定位，然后释放分支血管支架，主支血管支架挤压分支血管支架放分支血管支架，主支血管支架挤压分支血管支架Reverse（Internal）Crush：行行Provisional支架术时需要在支架术时需要在分支血管置入另一个支架时采用。分支血管置入另一个支架时采用。6F指引导管，首先释放主支指引导管，首先释放主支血管支架，通过主支支架的侧孔置入分支血管支架，通过预留血管支架，通过主支支架的侧孔置入分支血管支架，通过预留在主支的球囊对分支血管支架进行挤压在主支的球囊对分支血管支架进行挤压Inverse Crush：操作过程类似标准操作过程类似标准Crush支架术，但是分支支架术，但是分支血管的支架定位比主支血管更为近端，分支血管的支架去挤压血管的支架定位比主支血管更为近端，分支血管的支架去挤压主支血管支架主支血管支架Step Crush：与标准与标准Crush技术相同，但可在技术相同，但可在6F指引导管进行指引导管进行Stenting Techniques for the Stenting Techniques for the Treatment Bifurcation LesionsTreatment Bifurcation LesionsLouvard Y,Lefevre T,Morice MC,et al,Heart 2004;90:713-22Classic T beginning SBModified TCrush Classic T beginning MBProvision TCullotteTouching stentsTrouser legs and seatKissing stentsSkirt technique分叉病变包括左主干病变的治疗方法分叉病变包括左主干病变的治疗方法分叉病变包括左主干病变的治疗方法分叉病变包括左主干病变的治疗方法真性分叉病变真性分叉病变(主支和分支血管明显狭窄主支和分支血管明显狭窄)非非非非 是是是是主支血管置入支架，分支血管进行球囊扩张 分支血管适合支架术分支血管病变，从开口向远端弥漫超过3mm以上选择性置入两个支架（主支和分支）分支血管Provisional支架术分支血管Provisional 支架术或 KIO非非非非是是是是非非非非 是是是是绝大多数分叉病变在介入治疗结束时需要保持分绝大多数分叉病变在介入治疗结束时需要保持分绝大多数分叉病变在介入治疗结束时需要保持分绝大多数分叉病变在介入治疗结束时需要保持分支血管通畅，残余狭窄似乎意义不大支血管通畅，残余狭窄似乎意义不大支血管通畅，残余狭窄似乎意义不大支血管通畅，残余狭窄似乎意义不大如果分支血管达到最佳结果比较重要，在真性分如果分支血管达到最佳结果比较重要，在真性分如果分支血管达到最佳结果比较重要，在真性分如果分支血管达到最佳结果比较重要，在真性分叉病变中至少有叉病变中至少有叉病变中至少有叉病变中至少有5050的患者需要置入两个支架的患者需要置入两个支架的患者需要置入两个支架的患者需要置入两个支架分叉病变总结分叉病变总结1 1 支架策略支架策略支架策略支架策略 只有临床需要才进行冠脉造影随访只有临床需要才进行冠脉造影随访只有临床需要才进行冠脉造影随访只有临床需要才进行冠脉造影随访BMS era:One stent is better!%TVREnd-point at 6 months(%)p=NSNORDIC Bifurcation StudySteigen TK et al.Cir,2006,114:1955-61.MACE at 6 months（%）p=NSNORDIC Bifurcation StudySteigen TK et al.Cir,2006,114:1955-61.MI related to the procedure()p=0.008NORDIC Bifurcation StudySteigen TK et al.Cir,2006,114:1955-61.Stent Thrombosis(%)p=NSNORDIC Bifurcation StudySteigen TK et al.Cir,2006,114:1955-61.Nordic Stent Technique StudyA Randomized Study of Crush vs.Culotte Stent Techniques with Sirolimus Eluting Stents in Bifurcation LesionsErglis A et al.Circ Cardiovasc Intervent,2009;2:27-34Crush(n=209)Culotte(n=215)P value MACE4.3%3.7%0.87 Procedure-related Bio-markers increase15.5%8.8%0.08 In segment Restenosis 12.1%6.6%0.10 In stent Restenosis10.5%4.5%0.046Nordic II:Nordic III:A Prospective Randomized Trial of Side Branch Dilatation Strategies in Patients with Coronary Bifurcation Lesions Undergoing Treatment with a Single StentNO KISSINGKISSING%2.92.9Primary end point MACE(cardiac death,index lesion MI,TLR,stent thrombosis)after 6 monthsnsNiemela M.TCT 2009BBC ONE Study PRIMARY ENDPOINTComposite(9months)Death,MI,TVFSimpleComplexP value Death0.4%0.8%-Myocardial infarction3.6%11.2%0.001 Target vessel failure5.6%7.2%0.43 Primary endpoint8.0%15.2%0.009HR 2.02(1.17 to 3.47)David Hildick-Smith et al.Cir 2010;121:1235-1243David Hildick-Smith et al.Cir 2010;121:1235-1243BBC ONE Study PROCEDURAL ENDPOINTSimpleComplexP value Procedure Time,min57780.001 Fluoroscopy Time,min15220.001 Diamentor,cGy-cm2614079000.001 No.of Guidewires Used2.23.10.001 No.of Balloon Used2.34.00.001 No.of Stents Used1.22.20.001David Hildick-Smith et al.Cir 2010;121:1235-1243David Hildick-Smith et al.Cir 2010;121:1235-1243*One noncardiac death due to ischemic strokeCACTUS Study(Coronary Bifurcations:Application of the Crushing Technique Using Sirolimus-Eluting Stents)Colombo A,et al.Circulation.2009;119(1):71-8End pointCrush(%)Provisional T(%)Main-branch binary stenosis4.66.7Side-branch binary restenosis13.214.7MI0.50.5 TLR5.65.8TVR6.26.8Death00.5*Stent thrombosis1.71.1 Influence of Final Kissing in the CACTUS trialColombo A,et al.Circulation.2009;119(1):71-8End pointFinal Kissing(163 pts)No Final Kissing(14pts）P valueMain-branch stenosis4.7%16%0.03Side-branch restenosis11.9%36%0.001MI7.5%29%0.001TLR6.3%12.9%0.25Stent thrombosis0.9%6.5%0.060.60.40.2Main BranchSide Branch051015202530354015.5%(9/58)8.9%(8/90)37.9%(22/58)11.1%(10/90)0.210.34P=0.10P 0.05P=0.33P 0.001Restenosis(%)LLL(mm)0.320.52Important Role of final kissing balloon in Crush TechniqueGe L,et al.JACC,2005;46:613-620.Without FKBFKBKiss me,Kate!9 Month Clinical Outcomes After Crush StentingGe L,et al.JACC,2005;46:613-620.T-stenting(n=61)Crushing stenting(n=121)T-Stenting VS.Crushing Stenting14.0%TLRTVRTLRTVR31.1%16.5%32.8%14.1%11.3%28.9%31.1%ENTIRE COHORT05101520253035KISSING BALLOONP=0.01P=0.02P=0.03P=0.04Ge L,et al.Heart,2006;92:371-376Ge L,et al.Heart,2006;92:371-376Mini Crush with Double KissingJIM MH,et al.CCI,2007,69:969-975Non-randomized comparison;457 patients with bifurcation diseaseGalassi AR,et al.J Am Coll Cardiol Intv.2009;2:185-194.Mini-Crush vs.T-Provisional Techniques of DES Implantation in Bifurcation Lesions2-StentMini-CrushN=199T-Provisional1 StentN=170T-Provisional2 StentsN=88MI2.0%5.8%26.1%Stent ThrombosisBifurcation TLR8.5%14.5%17.4%MV Restenosis11.7%17.4%18.8%SB Restenosis8.5%18.8%26%Kissing Inflation88.2%83%52.2%Double-Kissing Crush:DKCRUSH-12-year f/uCrushDK CrushpTLR23.4%11.4%0.02MACE29.9%18.1%0.04Chen S et al,J Interv Cardiol 2009RCT in 312 patients at 12 centersKissing inflation in 76%of classical crush and 100%of DK Crush两步法对吻技术的重要性两步法对吻技术的重要性无对吻1步法对吻2步法对吻STEP CRUSH STEP CRUSH 技术步骤技术步骤技术步骤技术步骤先置入边支血管支架放置边支支架同时主支内放置球囊，挤压边支支架（可进行第一次Kissing）置入主支血管支架导丝再次进入边支最终完成主支和分支的Kissing扩张STEP CRUSHSTEP CRUSH