分叉病變介入治療我的-課件

1、分叉病變介入治療天津市第三中心醫(yī)院心臟中心 劉迎午分叉病變介入治療天津市第三中心醫(yī)院心臟中心ContentDefinition of bifurcation lesionClassification of bifurcation lesionStrategy of bifurcation-one stent or two stentsSpecific stent for bifurcationClinical casesContentDefinition of bifurcatidefinition累及到冠狀動脈分叉的病變冠狀動脈病變中分叉病變較為常見，約占經(jīng)皮冠狀動脈介入治療(pereuta

2、neous coronary intervention，PCI)的1520分叉病變的解剖結(jié)構(gòu)(斑塊負(fù)荷、斑塊位置、血管角度、血管直徑、分叉位置)千變?nèi)f化而治療過程中解剖結(jié)構(gòu)也會隨時改變(斑塊遷移、血管夾層) 所以無兩個完全一致的分叉病變，更無一種可適用于所有分叉病變的手術(shù)方法definition累及到冠狀動脈分叉的病變ClassificationClassificationClassification of bifurcation lesions according to plaque burdenA:DukeB:SanbornC:SafianD:LefevreClassification o

3、f bifurcation Medina A. et al. Rev Esp Cardiol. 2019; 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 ProximalSBMedina A. et al. Rev Esp Card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

4、 (especially MI / thrombosis)分叉病變介入治療- 關(guān)注熱點 一個好還是兩個好？分叉病變介入治療- 關(guān)注熱點 Stenting for bifurcation lesions in 2019主支放支架，分支臨時決定Stenting the main vessel with provisional stenting of the side branch Stenting for bifurcation lesioProvisional Stenting Strategy If 2nd stent is needed for side branch following m

5、ain vessel stenting Modified T-stenting Reverse crushing Culotte stentingProvisional Stenting Strategy分支血管的保護與放置支架 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分支血管的保護與放置支架 并非所有分支血管同等重要!Side branch closure after PCISide branch closure after PCISide-branch may be compromised f

6、ollowing 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 th

7、rombus tooSide-branch may be compromisedDifferent 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 techniq

8、ue/The inverted crush technique)The culottes stenting techniqueThe Y stenting techniqueThe skirt techniqueDifferent techniques of two sThe V stenting techniqueThe V stenting techniqueThe simultaneous kissing stents techniqueThe simultaneous kissing stentThe V stenting and the simultaneous kissing st

9、enting 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叉病變，近段無病變或無須支架。 The V stenting and the simultaThe 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. The V stenting and the simultaThe V stenting and the simultaneous kissin

10、g 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。The V stenting and the simultaThe T stenting techniqueThe T stenting techniqueThe modified T stenting techniqueThe modified T stenting techniThe 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。The T and modified T s

11、tenting Colombo et al Circulation 2019; 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 stenting techniqueColombo et al Circulation 201RESEARCH bifurcation subgroupRR of different techniquesThe hig

12、h 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, 2019, 91:115-8Effects of the T stenting techniqueRESEARCH bifurcation subgroupRV stenting vs T stentingSharma et al.V ste

13、nting:100Provisional T stenting: 10032% subjects received Cypher stent and RVD was 3.32mm。V stenting vs T stentingSharmaProvisional T stentingProvisional T stenting優(yōu)點:Higher procedural success rateLower expenseLower complicationsLower re-PCI7mons TLR 15%。Lefevre et al: Provisional T stenting is the

14、golden standard to treat false bifurcation lesion(tpye2, 3 and 4a), most subjects only need one stent implantation。Provisional T stenting優(yōu)點:Provisional T stentingThe crush techniqueThe crush techniqueThe crush technique優(yōu)點:可以保證兩條分支的立刻開通,這點對保護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困難，操作復(fù)雜。The

15、crush technique優(yōu)點:Ge et al. JACC 2019; 46: 613Long term outcome of “Crush”Stenting technique Ge et al. JACC 2019; 46: 613Lo6 mons RR Colombo et al. The crush technique6 mons RR Colombo et al. The reverse crush or internal crush techniqueThe reverse crush or internal The reverse crush or internal cru

16、sh technique主要用于臨時分支支架植入provisional SB stenting. The reverse crush or internal 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。The reverse crush or internal The step crush techniquedouble kissingThe step crush techniquedoubleCa

17、se: The step crush techniqueCase: The step crush technique分叉病變介入治療我的-課件First kissingFirst kissing分叉病變介入治療我的-課件Second kissingSecond kissingFinal resultFinal resultThe 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. The step crush techn

18、ique優(yōu)點:The inverted crush techniqueThe inverted crush techniqueThe 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. The inverted crush technique適用Restenosis in MV = 12.2%Restenosis in SB = 2%Galassi et al. Cath & Cardiovas. Intervn 2019; 69: 976-83Restenosis

19、 in MV = 12.2%GalassThe culottes stenting techniqueThe culottes stenting techniquThe 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。The culottes stenting techniquNordic Bifurcation Study II- The Nordic Stent Technique Study: Crush vs Culotte stentingNordic Bifurcation

20、Study IINordic Bifurcation Study II- The Nordic Stent Technique Study: Crush vs Culotte stentingIndividual end-point at 6 months Nordic Bifurcation Study IIIndThe Y stenting techniqueThe Y stenting techniqueThe skirt techniqueThe skirt techniqueThe 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The Y stenting technique and The Y stenting technique77 case being with bifurca