分叉病變介入技巧教學(xué)課件

1、分叉病變介入技巧第1頁，共51頁。Classification of bifurcation lesions according to plaque burdenA:DukeB:SanbornC:SafianD:Lefevre第2頁，共51頁。Medina 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

2、DistalMB ProximalSB第3頁，共51頁。一個好還是兩個好？如果選個，應(yīng)該采取何種策略 ?策略選擇的根據(jù) 簡單化 vs 復(fù)雜化 循證結(jié)果 vs 個人選擇 并發(fā)癥率 (especially MI / thrombosis)分叉病變介入治療- 關(guān)注熱點 第4頁，共51頁。Stenting for bifurcation lesions in 2007主支放支架，分支臨時決定Stenting the main vessel with provisional stenting of the side branch 第5頁，共51頁。Provisional Stenting Strateg

3、y If 2nd stent is needed for side branch following main vessel stenting Modified T-stenting Reverse crushing Culotte stenting第6頁，共51頁。分支血管的保護(hù)與放置支架 并非所有分支血管同等重要! 根據(jù)以下情況實施分支血管保護(hù)和支架植入 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 分支與主支成角程度第7頁，共51頁。Side branch closure after PCI第8頁，共51頁。Side-branch may be compromised follow

4、ing main vessel stentingPre-treatmentAfter 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 thrombu

5、s too第9頁，共51頁。Different techniques of two stents by intention to treat bifurcation lesionsThe V stenting techniqueThe simultaneous kissing stents techniqueThe T stenting and modified T stenting technique The crush technique(The reverse crush technique/The step crush technique/The inverted crush tech

6、nique)The culottes stenting techniqueThe Y stenting techniqueThe skirt technique第10頁，共51頁。The V stenting technique第11頁，共51頁。The simultaneous kissing stents technique第12頁，共51頁。The V stenting and the simultaneous kissing stenting technique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，并且左主干短或無病變。理想夾角90。V支架也適合于其他部位的分

7、叉病變，近段無病變或無須支架。 第13頁，共51頁。The V stenting and the simultaneous kissing stenting technique優(yōu)點:保證不會丟失分支。 對吻技術(shù)時無須 re-cross any stent. 第14頁，共51頁。The V stenting and the simultaneous kissing stenting technique缺點:雙支架近端定位較困難；不可避免造成其中一個支架偏心，往往引起 a gap。第15頁，共51頁。The T stenting technique第16頁，共51頁。The modified T

8、stenting technique第17頁，共51頁。The T and modified T stenting technique優(yōu)點:較crush 技術(shù)容易完成。缺點:大多數(shù)情況下，分支開口不能完全覆蓋。第18頁，共51頁。Colombo et al Circulation 2004; 109:1244-1249* High cross-over rate from Stent + Balloon to Stent + Stent group (22/43, 51%)Cypher Bifurcation Stenting ( T-stenting )Effects of the T st

9、enting technique第19頁，共51頁。RESEARCH bifurcation subgroupRR of different techniquesThe high restenosis rate of T stenting technique may be related to the 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 st

10、enting technique第20頁，共51頁。V stenting vs T stentingSharma et al.V stenting:100Provisional T stenting: 10032% subjects received Cypher stent and RVD was 3.32mm。第21頁，共51頁。Provisional T stenting第22頁，共51頁。優(yōu)點:Higher procedural success rateLower expenseLower complicationsLower re-PCI7mons TLR 15%。Lefevre e

11、t al: Provisional T stenting is the golden standard to treat false bifurcation lesion(tpye2, 3 and 4a), most subjects only need one stent implantation。Provisional T stenting第23頁，共51頁。The crush technique第24頁，共51頁。The crush technique優(yōu)點:可以保證兩條分支的立刻開通,這點對保護(hù)功能上重要的分支非常重要?？梢酝耆采w分支開口。缺點:由于有多層支架金屬，導(dǎo)絲和球囊再次通過較

12、困難，操作復(fù)雜。第25頁，共51頁。Ge et al. JACC 2005; 46: 613Long term outcome of “Crush”Stenting technique 第26頁，共51頁。6 mons RR Colombo et al. The crush technique第27頁，共51頁。The reverse crush or internal crush technique第28頁，共51頁。The reverse crush or internal crush technique主要用于臨時分支支架植入provisional SB stenting. 第29頁，共

13、51頁。The reverse crush or internal crush technique 優(yōu)點:可以保證兩條分支的立刻開通，6F guiding catheter可以完成操作。 缺點: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。第30頁，共51頁。The step crush techniquedouble kissing第31頁，共51頁。Case: The step crush technique第32頁，共51頁。第33頁，共51頁。First kissing第34頁，共51頁。第35頁，共51頁。Second kissing第36頁，共51頁。Final resu

14、lt第37頁，共51頁。The step crush technique優(yōu)點:6F guiding catheter可以完成操作，特別適合于橈動脈經(jīng)路，第二次導(dǎo)絲和球囊再次通過較容易成功。 缺點:同 the standard crush technique. 第38頁，共51頁。The inverted crush technique第39頁，共51頁。The inverted crush technique適用于分支管徑不小于主支的情況。分支支架擠壓crush主支支架。缺點:同 the standard crush technique. 第40頁，共51頁。Restenosis in MV

15、= 12.2%Restenosis in SB = 2%Galassi et al. Cath & Cardiovas. Intervn 2007; 69: 976-83第41頁，共51頁。The culottes stenting technique第42頁，共51頁。The culottes stenting technique優(yōu)點:適合于任何角度的分叉病變，并提供完美的分支開口覆蓋。缺點:分叉病變近段雙層支架重疊，金屬密度高。第43頁，共51頁。Nordic Bifurcation Study II- The Nordic Stent Technique Study: Crush vs

16、Culotte stenting第44頁，共51頁。Nordic Bifurcation Study II- The Nordic Stent Technique Study: Crush vs Culotte stentingIndividual end-point at 6 months 第45頁，共51頁。The Y stenting technique第46頁，共51頁。The skirt technique第47頁，共51頁。The Y stenting technique and The skirt technique優(yōu)點: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

17、要求保證導(dǎo)絲進(jìn)入兩分支。缺點: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DES易破壞polymer 。近端支架很難完全連接遠(yuǎn)端雙支架。采用Y 支架技術(shù)時，多數(shù)術(shù)者將分支導(dǎo)絲回撤并放入主支，這時釋放近端支架可以更好連接遠(yuǎn)端支架第48頁，共51頁。The Y stenting technique77 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;82:7A50S第49頁，共51頁。Classification of bifurcation lesions according to plaque burdenA:DukeB:SanbornC:SafianD:LefevreThe V stenting techniqueThe simultaneous kissing stents techniqueThe T stenting and modified T