基礎(chǔ)醫(yī)學(xué)CTO病變的技巧冠心病最新進(jìn)展課件

慢性完全閉塞病變介入技巧和器械選擇北京安貞醫(yī)院呂樹錚教授1h慢性完全閉塞病變介入技巧和器械選擇北京安貞醫(yī)院1h慢性完全閉塞病變介入技巧和器械選擇慢性完全閉塞病變的相關(guān)概念慢性完全閉塞病變的病理結(jié)構(gòu)和特點(diǎn)CTO介入的導(dǎo)絲選擇CTO病變的支架選擇2h慢性完全閉塞病變介入技巧和器械選擇慢性完全閉塞病變的相關(guān)概念CTO的定義閉塞時(shí)間大于3個(gè)月的病變3hCTO的定義閉塞時(shí)間大于3個(gè)月的病變3hCTO病變形成時(shí)間的判斷AMI的時(shí)間癥狀加重的時(shí)間側(cè)枝循環(huán)形成的多少及側(cè)枝的直徑4hCTO病變形成時(shí)間的判斷AMI的時(shí)間4hCTO病變長(zhǎng)度的判斷順行顯影逆行顯影雙向造影5hCTO病變長(zhǎng)度的判斷順行顯影5h順行顯影6h順行顯影6h逆行顯影7h逆行顯影7hCTO病變的病理結(jié)構(gòu)1.壞死脂核、膽固醇結(jié)晶及鈣化8hCTO病變的病理結(jié)構(gòu)1.壞死脂核、膽固醇結(jié)晶及鈣化8hCTO病變的病理結(jié)構(gòu)2.細(xì)胞外基質(zhì)：膠原、鈣化9hCTO病變的病理結(jié)構(gòu)2.細(xì)胞外基質(zhì)：膠原、鈣化9hCTO病變的病理結(jié)構(gòu)3.微血管10hCTO病變的病理結(jié)構(gòu)3.微血管10hCTO病變的類型重度狹窄慢性閉塞輕中度狹窄慢性閉塞11hCTO病變的類型重度狹窄慢性閉塞11h重度狹窄慢性閉塞?主要由纖維化和鈣化的粥樣硬化斑塊組成?短閉塞段：纖維帽位于閉塞段的兩側(cè)邊緣，中間為血管壁重塑形成的組織，閉塞時(shí)間一般為3個(gè)月以上，重塑的組織中含有大量的纖維組織?長(zhǎng)閉塞段：常常有血栓的成分，閉塞段往往是纖維組織與血栓相間分布。這種病變導(dǎo)絲很難通過，成功率只有50～70%12h重度狹窄慢性閉塞?主要由纖維化和鈣化的粥樣硬化斑塊組成12h輕中度狹窄慢性閉塞脂核纖維組織陳舊血栓原有輕中度狹窄病變，班塊破裂，未及時(shí)治療，導(dǎo)致血管慢性閉塞，新的閉塞處遠(yuǎn)離原有狹窄斑塊，導(dǎo)絲注意尋找閉塞斑塊13h輕中度狹窄慢性閉塞脂核纖維組織陳舊血栓原有輕中度狹窄病變，班CTO病變的病理特點(diǎn)粥樣斑塊+鈣化慢性發(fā)展融合而成14hCTO病變的病理特點(diǎn)粥樣斑塊+鈣化慢性發(fā)展融合而成14hCTO病變的病理特點(diǎn)斑塊破潰形成血栓機(jī)化而成15hCTO病變的病理特點(diǎn)斑塊破潰形成血栓機(jī)化而成15hCTO介入的導(dǎo)絲選擇16hCTO介入的導(dǎo)絲選擇16h導(dǎo)絲的結(jié)構(gòu)17h導(dǎo)絲的結(jié)構(gòu)17h導(dǎo)引導(dǎo)絲的性能?調(diào)節(jié)力：導(dǎo)絲尖端和中心鋼絲結(jié)構(gòu)?柔軟性：導(dǎo)絲的直徑、尖端結(jié)構(gòu)和連接段變系程度?推送力：中心鋼絲的硬度和中間變細(xì)方式?支持力：中心鋼絲的直徑和材料18h導(dǎo)引導(dǎo)絲的性能?調(diào)節(jié)力：導(dǎo)絲尖端和中心鋼絲結(jié)構(gòu)18h處理CTO病變時(shí)常用的導(dǎo)絲超滑導(dǎo)絲：如PTGraphicIntermediate、PT2、Shinobi、CrossNT、Whisper等Coil型導(dǎo)絲：ACSIntermediateStandard、CrossIT100-400、Miracle3-12及Conquest(Pro)9-12等19h處理CTO病變時(shí)常用的導(dǎo)絲超滑導(dǎo)絲：如PTGraphic處理CTO病變時(shí)常用導(dǎo)絲超滑導(dǎo)絲20h處理CTO病變時(shí)常用導(dǎo)絲超滑導(dǎo)絲20hSCIMEDPT221hSCIMEDPT221hThecombinationofapolymercoverandhydrophiliccoatingprovidesoutstandinglubricity.22hThecombinationofapolymercSCIMEDPTGraphicIntermediate

Uni-bodycorewithlong,smoothtaperfromsupportregiontotipHydrophilic-coated,polymersleeveandtipIntermediatewirewithslightlystiffertipCrossingperformanceofpolymertipwithvisibilityofspringtip23hSCIMEDPTGraphicIntermediateTerumoCrossNT24hTerumoCrossNT24hWHISPER?RedefinesPolymerWirePerformanceResponsEase?grindtechnologyDURASTEEL?corematerialPolymerCoated/HydrocoatDistalsegmentSofttipdesignedforfrontlineuse25hWHISPER?RedefinesPolymerWirHI-TORQUEPILOT?Design26hHI-TORQUEPILOT?Design26hHI-TORQUEPILOT?FamilyProductDescriptionDesignHighlights: ?Polymer-tip,hydrophilic ?Core-to-tipwithmoderatesupport ?Graduatedtipstiffnessinthefamily ?ModifiedRESPONSEASE?parabolicgrind ?DURASTEEL?corematerial ?Singlelesionmeasurementmarker27hHI-TORQUEPILOT?FamilyProducTheHI-TORQUEPILOT?familyofguidewiresoffersachoiceofwiresthatvaryintipstiffnesstoaddressawidevarietyoflesionmorphology.Tipcoilsbeneaththepolymerhelpfacilitatetipshaping.28hTheHI-TORQUEPILOT?familyofModifiedRESPONSEASE?ParabolicGrindThismodifiedRESPONSEASE?designprovidesadditionalsupport,excellenttorquetransmissionandin-lesiontipcontrol.29hModifiedRESPONSEASE?ParaboliTheHI-TORQUEPILOT?guidewiresmaintainedtheirtipshapebetterthancompetitivewiresafterpassingthrough

atortuouspathmodel.TheDURASTEEL?corematerialoftheHI-TORQUEPILOT?familyisstrongerthanconventionalstainlesssteelforimprovedcorestrengthandtipshaperetention.DURASTEEL?withstandsmorepullingforcethanregular304vstainlesssteel.30hTheHI-TORQUEPILOT?guidewir.007”CorewireSupportPTFE噴涂–近端黑色的PTFE袖套延伸至遠(yuǎn)端頭部平的顯影線圈Shinobi&ShinobiPlus.010”CorewiresupportSHINOBIPlusSHINOBIWIZDOM的核心鋼絲STABILIZERPlus的核心鋼絲31h.007”CorewireSupportPTFE噴涂處理CTO病變時(shí)常用的導(dǎo)絲Coil型導(dǎo)絲32h處理CTO病變時(shí)常用的導(dǎo)絲Coil型導(dǎo)絲32hACSIntermediate&Standard?Intermediate：中軟纏繞頭端，core-to-tip，錐行漸變的中間軸?Standard：標(biāo)準(zhǔn)纏繞頭端，不易扭曲的推送桿33hACSIntermediate&Standard?ACS導(dǎo)絲34hACS導(dǎo)絲34hAGuidetoACSHI-TORQUEGuideWires35hAGuidetoACSHI-TORQUEGuideCrossIT36hCrossIT36hCrossIT

100-40037hCrossIT

100-40037hCrossIT特性38hCrossIT特性38hSmoothShaftwithFluororesincoatingJointlessSpringCoilPropertyofASAHINEO’S

PTCAGUIDEWIREFamilyWiththeunibodycorewhichispreciselytapereduptotheextremeend,withoutadditionalribbon,thushighlygoodtorqueabilityisachieved.Shafthasfluororesincoating,whichprovideshighoperativityandgoodmatchingwithballooncatheter.OnePieceCoreWireJointlessspringcoilmadeoftwodifferentmetalsprovidesgoodtorqueabilityandexcellentslidepropertywithdevicesMedicalGradeSiliconeCoating39hSmoothShaftwithFluororesinJointlessSpringCoilstructureimage

ASAHIJointlessspringcoil2-coil-connectedstructure

Jointlessstructureenablesverysmoothcurvingbentofthecoil/guidewireintortuousvessel.While,2-coil-bittenconnectioncoilmaymakesquarebent.Soldering40hJointlessSpringCoilstructuSoft/SoftAG141000Radio-opacity3cmCoil30cmDiameter0.014inchLength175cmFlexibilitySupportMoreMoreLessThisisafirstchoiceguidewirewithhightorqueresponseandexcellentsteerabilitybecauseoftheuniquecoreproperty.（Tipload0.7G）Intermediate/MediumAG142000Radio-opacity3cmCoil30cmDiameter0.014inchLength175cmFlexibilitySupportMoreMoreLessThisisaguidewirewithagoodbalanceoftipflexibilityandsupportperformance.（Tipload3.0G）Standard/StandardAG143000Radio-opacity3cmCoil30cmDiameter0.014inchLength175cmFlexibilitySupportMoreMoreLessImprovedtipstiffnesswithouruniquecoretaperdesign.（Tipload6.5G）Light/LightAG145000Radio-opacity3cmCoil20cmDiameter0.014inchLength175cmASAHINEO’SPTCAGuideWireLine-upImprovedlubricityandgoodtipshapememorywithouruniquecoredesign.Excellenttorqueresponse.Thiswirehasaflexibletipandcanbeusedasafirstchoicewireforalmostallprocedures.（Tipload0.5G）SupportFlexibilityMoreMoreLess41hSoft/SoftFlexibilitySupportM（Tipload3.0G）Miracle4.5/Miraclebros4.5AG14M045Radio-opacity11cmCoil11cmDiameter0.014inchLength175cmFlexibilitySupportMoreMoreLess（Tipload4.5G）Miracle6/Miraclebros6AG14M060Radio-opacity11cmCoil11cmDiameter0.014inchLength175cmFlexibilitySupportMoreMoreLess（Tipload6.0G）Miracle12/Miraclebros12AG14M070Radio-opacity11cmCoil11cmDiameter0.014inchLength175cmFlexibilitySupportMoreMoreLow（Tipload12.0G）Miracle3/Miraclebros3AG14M050Radio-opacity11cmCoil11cmDiameter0.014inchLength175cmMiracleSeriesApplyingthestructurewhichfurtherimprovestorqueperformanceforCTOuse.Thetipparthasthestructurewhichisdifficulttobetrappedbythelesions.FlexibilitySupportMoreMoreLess42h（Tipload3.0G）Miracle4.5/MiStructureofConquestPro/Pro12

0.014”200mmRadiopaqueSpringCoil0.009”StainlessCoreWirePTFECoatingHydrophilicCoatingAGH143090ConquestPro43hStructureofConquestPro/Pro1GrandSlam/GrandSlam

AG141002Radio-opacity4cmCoil4cmDiameter0.014inchLength175cmFlexibilitySupportMoreMoreLessInspiteofitsflexibletip,thecoreisalsodesignedtoprovidestrongsupportwhenapproachingthetortuouslesions.（Tipload0.7G）MarkerWireAG141010Radio-opacity3cmCoil30cmDiameter0.014inchLength175cmFlexibilitySupportMoreMoreLessSameleveloftipstiffnessasSOFT.Ithastenmarkersstartingafter50mmfromthetiptoscalelesionsandpositiondevices.（Tipload0.7G）Rinato/ProwaterAG146000Radio-opacity3cmCoil20cmDiameter0.014inchLength175cmCONQUEST/ConfianzaAG143090Radio-opacity20cmCoil20cmDiameter0.014inchLength175cmThiswireisdevelopedforCTOuse.HigherpenetrationabilitythanMiracles.Diameteroftipcoilistaperedto0.009inch(φ0.23mm).（Tipload9.0G）FlexibilitySupportMoreMoreLessHydrophiliccoatingoverthecoilspring(after3cmfromthetip).NewlydesignedoriginalcoreshaftgivesadequatelyhighersupportperformancethanSOFT,improvedtorqueperformance.（Tipload0.8G）FlexibilitySupportMoreMoreLess44hGrandSlam/GrandSlamFlexib45h45h46h46h如何選擇導(dǎo)絲47h如何選擇導(dǎo)絲47h

下列情況首選超滑涂層的導(dǎo)絲1.閉塞段近端無邊支開口，病變長(zhǎng)度<20mm，血管殘端程鼠尾狀狀。鼠尾狀48h下列情況首選超滑涂層的導(dǎo)絲1.閉塞段近端無邊支開口，病變下列情況首選超滑涂層的導(dǎo)絲2.閉塞段有彎曲的閉塞段扭曲49h下列情況首選超滑涂層的導(dǎo)絲2.閉塞段有彎曲的閉塞段扭曲49下列情況首選超滑涂層的導(dǎo)絲3.閉塞段近端及遠(yuǎn)端彎曲重的近端過度扭曲遠(yuǎn)端過度扭曲50h下列情況首選超滑涂層的導(dǎo)絲3.閉塞段近端及遠(yuǎn)端彎曲重的近端下列情況首選尖端纏繞形導(dǎo)絲1.血管殘端呈齊頭的2.閉塞段近端有分支開口的齊頭閉塞51h下列情況首選尖端纏繞形導(dǎo)絲1.血管殘端呈齊頭的齊頭閉塞51下列情況首選尖端纏繞形導(dǎo)絲3.閉塞段長(zhǎng)度>20mm4.閉塞時(shí)間>6個(gè)月52h下列情況首選尖端纏繞形導(dǎo)絲3.閉塞段長(zhǎng)度>20mm52h導(dǎo)絲通過閉塞段時(shí)的情況1.導(dǎo)絲通過閉塞1-6個(gè)月內(nèi)、長(zhǎng)度<20mm沒有鈣化的病變時(shí)較順利，成功率高。53h導(dǎo)絲通過閉塞段時(shí)的情況1.導(dǎo)絲通過閉塞1-6個(gè)月內(nèi)、長(zhǎng)度<導(dǎo)絲通過閉塞段時(shí)的情況2.導(dǎo)絲通過有硬核的閉塞段時(shí)導(dǎo)絲無法穿透斑塊，其尖端沿斑塊邊緣穿透血管壁導(dǎo)絲強(qiáng)行穿過硬斑塊核54h導(dǎo)絲通過閉塞段時(shí)的情況2.導(dǎo)絲通過有硬核的閉塞段時(shí)導(dǎo)絲無法如何判斷導(dǎo)絲是否在真腔1.根據(jù)不同的投照角度55h如何判斷導(dǎo)絲是否在真腔1.根據(jù)不同的投照角度55h如何判斷導(dǎo)絲是否在真腔2.根據(jù)導(dǎo)絲尖端的形態(tài)和走性真腔中導(dǎo)絲尖端彎形“J”存在，導(dǎo)絲可自由旋轉(zhuǎn)，可沿主支血管走形前進(jìn)，也能進(jìn)入相應(yīng)分支，并每次均能規(guī)律進(jìn)入同一走行分支。56h如何判斷導(dǎo)絲是否在真腔2.根據(jù)導(dǎo)絲尖端的形態(tài)和走性56h如何判斷導(dǎo)絲是否在真腔3.通過側(cè)支循環(huán)顯示閉塞段遠(yuǎn)端造影通過逆行或順行側(cè)支顯示閉塞段遠(yuǎn)端，多角度透射觀察導(dǎo)絲是否在真腔；在導(dǎo)絲即將通過閉塞段進(jìn)入閉塞段遠(yuǎn)端血管真腔時(shí)尤應(yīng)謹(jǐn)慎，導(dǎo)絲每前進(jìn)1-2mm就應(yīng)多角度投照，調(diào)整導(dǎo)絲尖端方向，防止損傷閉塞段遠(yuǎn)端血管，造成長(zhǎng)夾層而不可修復(fù)。57h如何判斷導(dǎo)絲是否在真腔3.通過側(cè)支循環(huán)顯示閉塞段遠(yuǎn)端57h如何判斷導(dǎo)絲是否在真腔4.通過OTW球囊造影判斷一旦導(dǎo)絲在假腔，造影時(shí)造影劑沖擊損傷血管內(nèi)膜，形成全程長(zhǎng)夾層，導(dǎo)絲無法在進(jìn)真腔，并造成遠(yuǎn)端血管閉塞－－心梗。

此法很少用.58h如何判斷導(dǎo)絲是否在真腔4.通過OTW球囊造影判斷導(dǎo)絲成形及操作技巧59h導(dǎo)絲成形及操作技巧59hCTO病變導(dǎo)絲尖端成形半徑要小成形半徑大，則前向力被分解，導(dǎo)絲不易前行成形半徑大，對(duì)血管壁損傷大成形半徑大，不易調(diào)整方向60hCTO病變導(dǎo)絲尖端成形半徑要小成形半徑大，則前向力被分解，導(dǎo)閉塞段近端成角大的病變要先將導(dǎo)絲頭端塑形成較大的角度，使其易于通過閉塞段近端的扭曲，并將微導(dǎo)管或OTW球囊導(dǎo)入到病變處；再將導(dǎo)絲重新塑形成小角度或換用塑形成小角度硬導(dǎo)絲，嘗試通過病變。61h閉塞段近端成角大的病變要先將導(dǎo)絲頭端塑形成較大的角度，使其易閉塞段較硬的病變對(duì)于較硬的病變估計(jì)球囊不易通過者，除在導(dǎo)絲頭端塑形成角后，可在導(dǎo)絲尖端再塑形第二個(gè)小角（只適用于CrossIT300-400、ConquestPro9-12及Miracle9-12），將閉塞病變“掏”大，但導(dǎo)絲旋轉(zhuǎn)速度不能快。62h閉塞段較硬的病變對(duì)于較硬的病變估計(jì)球囊不易通過者，除在導(dǎo)絲頭63h63hCTO病變的支架選擇64hCTO病變的支架選擇64hCTO病變中PTCA和支架植入術(shù)比較：再狹窄發(fā)生率65hCTO病變中PTCA和支架植入術(shù)比較：再狹窄發(fā)生率65hCTO病變中PTCA和支架植入術(shù)比較：再閉塞發(fā)生率66hCTO病變中PTCA和支架植入術(shù)比較：再閉塞發(fā)生率66h相對(duì)于單純PTCA術(shù)，金屬裸支架降低了再狹窄和再閉塞率，但仍然比較高．與金屬裸支架相比雷帕霉素藥物支架明顯降低了低或中危再狹窄風(fēng)險(xiǎn)病人的晚期管腔丟失和再狹窄率

67h相對(duì)于單純PTCA術(shù)，金屬裸支架降低了再狹窄和再閉塞率，但仍CTO中應(yīng)用CYPHERstent的經(jīng)驗(yàn)HoyeA.,etal.,JAmCollCardiol2004;43(11):1954-8.-56例CYPHER治療GeL.,etal.,EurHeartJ2005:26(11):1056-62-122例CYPHER治療NakamuraS.,etal.,AmJCardiol2005;95:161-6-60例CYPHER治療TheSICTOStudyCYPHERTM

Sirolimus-elutingstent

in

Chronic

Total

OcclusionThePRISONII

StudyPrimaryStentingofOccludedNativeCoronaryArteries

68hCTO中應(yīng)用CYPHERstent的經(jīng)驗(yàn)HoyeA.,SICTOSTUDYDESIGNAmulticenter,prospective,non-randomizedstudytoassessthefeasibilityandrestenosis/reocclusionratesofcoronarystentingwiththeCypherTMSirolimus-elutingstentinpatientswithchronictotalocclusion25patientsweretreatedwiththeCypherTMSirolimus-elutingstentaftersuccessfulballoonangioplastyandIVUSexamination.Clinicalfollow-upat30days,6,12,18and24months-repeatangiographyandIVUSat6monthsfollow-up.69hSICTOSTUDYDESIGN25patientsSICTO

–ConclusionInthisfeasibilitystudytheCYPHERTMSirolimus-elutingstentwasveryeffectiveinthetreatmentofCTO,withverylowratesofTLR(0%),MACE(0%)andTVR(8%)

comparedtohistoricaldatawithbarestents(30-50%).TheCYPHERTMSirolimus-elutingstentsignificantlyinhibitsintimalhyperplasiainCTO.ThesepreliminarydatawillcomeinadditionoflargerdatabasewithCTOsubpopulation(e.g.e-Cypher)70hSICTO–ConclusionInthisfeas

PRISONIIStudyTocomparetheimmediateandlong-termangiographicandclinicalresultsofBMS(BxVelocity?)implantationwithSirolimus-elutingStent(CYPHER?)implantationforthetreatmentofCTO71hPRISONIIStudyTocompare6-monthClinicalFollow-upClinicalEvent(%)204P<0.001248228194320P=0.003P=0.009P=0.001P=NSP=NS072h6-monthClinicalFollow-upClin6-monthAngiographicFollow-up

In-StentBMS(n=94)SES(n=94)pvalueRef.diameter(mm)3.01±0.853.44±0.54<0.0001MLD(mm)1.47±0.832.48±0.80<0.0001%diam.stenosis48.75±26.5222.01±20.98<0.0001LateLoss(mm)1.09±0.910.05±0.81<0.0001Netgain(mm)1.30±0.882.33±0.85<0.0001Lossindex0.45±0.37-0.02±0.41<0.000173h6-monthAngiographicFollow-upP<0.0001P<0.00014136117%73%81%AngiographicBinaryRestenosis

RelativeRiskReduction74hP<0.0001P<0.00014136117%73%8ConclusionsAscomparedwithbaremetalstents,theCYPHER?sirolimus-elutingstentimplantationinCTOissuperiorwithasignificantreductioninbinaryin-segmentandin-stentrestenosisAsaconsequencethisresultedinasignificantreductionofTLRandTVRAlowrateofsub-acuteandlatestentthrombosiswasobservedinbothgroupsPRISONII75hConclusionsAscomparedwithbaThanks

Q&A76hThanksQ&A76h慢性完全閉塞病變介入技巧和器械選擇北京安貞醫(yī)院呂樹錚教授77h慢性完全閉塞病變介入技巧和器械選擇北京安貞醫(yī)院1h慢性完全閉塞病變介入技巧和器械選擇慢性完全閉塞病變的相關(guān)概念慢性完全閉塞病變的病理結(jié)構(gòu)和特點(diǎn)CTO介入的導(dǎo)絲選擇CTO病變的支架選擇78h慢性完全閉塞病變介入技巧和器械選擇慢性完全閉塞病變的相關(guān)概念CTO的定義閉塞時(shí)間大于3個(gè)月的病變79hCTO的定義閉塞時(shí)間大于3個(gè)月的病變3hCTO病變形成時(shí)間的判斷AMI的時(shí)間癥狀加重的時(shí)間側(cè)枝循環(huán)形成的多少及側(cè)枝的直徑80hCTO病變形成時(shí)間的判斷AMI的時(shí)間4hCTO病變長(zhǎng)度的判斷順行顯影逆行顯影雙向造影81hCTO病變長(zhǎng)度的判斷順行顯影5h順行顯影82h順行顯影6h逆行顯影83h逆行顯影7hCTO病變的病理結(jié)構(gòu)1.壞死脂核、膽固醇結(jié)晶及鈣化84hCTO病變的病理結(jié)構(gòu)1.壞死脂核、膽固醇結(jié)晶及鈣化8hCTO病變的病理結(jié)構(gòu)2.細(xì)胞外基質(zhì)：膠原、鈣化85hCTO病變的病理結(jié)構(gòu)2.細(xì)胞外基質(zhì)：膠原、鈣化9hCTO病變的病理結(jié)構(gòu)3.微血管86hCTO病變的病理結(jié)構(gòu)3.微血管10hCTO病變的類型重度狹窄慢性閉塞輕中度狹窄慢性閉塞87hCTO病變的類型重度狹窄慢性閉塞11h重度狹窄慢性閉塞?主要由纖維化和鈣化的粥樣硬化斑塊組成?短閉塞段：纖維帽位于閉塞段的兩側(cè)邊緣，中間為血管壁重塑形成的組織，閉塞時(shí)間一般為3個(gè)月以上，重塑的組織中含有大量的纖維組織?長(zhǎng)閉塞段：常常有血栓的成分，閉塞段往往是纖維組織與血栓相間分布。這種病變導(dǎo)絲很難通過，成功率只有50～70%88h重度狹窄慢性閉塞?主要由纖維化和鈣化的粥樣硬化斑塊組成12h輕中度狹窄慢性閉塞脂核纖維組織陳舊血栓原有輕中度狹窄病變，班塊破裂，未及時(shí)治療，導(dǎo)致血管慢性閉塞，新的閉塞處遠(yuǎn)離原有狹窄斑塊，導(dǎo)絲注意尋找閉塞斑塊89h輕中度狹窄慢性閉塞脂核纖維組織陳舊血栓原有輕中度狹窄病變，班CTO病變的病理特點(diǎn)粥樣斑塊+鈣化慢性發(fā)展融合而成90hCTO病變的病理特點(diǎn)粥樣斑塊+鈣化慢性發(fā)展融合而成14hCTO病變的病理特點(diǎn)斑塊破潰形成血栓機(jī)化而成91hCTO病變的病理特點(diǎn)斑塊破潰形成血栓機(jī)化而成15hCTO介入的導(dǎo)絲選擇92hCTO介入的導(dǎo)絲選擇16h導(dǎo)絲的結(jié)構(gòu)93h導(dǎo)絲的結(jié)構(gòu)17h導(dǎo)引導(dǎo)絲的性能?調(diào)節(jié)力：導(dǎo)絲尖端和中心鋼絲結(jié)構(gòu)?柔軟性：導(dǎo)絲的直徑、尖端結(jié)構(gòu)和連接段變系程度?推送力：中心鋼絲的硬度和中間變細(xì)方式?支持力：中心鋼絲的直徑和材料94h導(dǎo)引導(dǎo)絲的性能?調(diào)節(jié)力：導(dǎo)絲尖端和中心鋼絲結(jié)構(gòu)18h處理CTO病變時(shí)常用的導(dǎo)絲超滑導(dǎo)絲：如PTGraphicIntermediate、PT2、Shinobi、CrossNT、Whisper等Coil型導(dǎo)絲：ACSIntermediateStandard、CrossIT100-400、Miracle3-12及Conquest(Pro)9-12等95h處理CTO病變時(shí)常用的導(dǎo)絲超滑導(dǎo)絲：如PTGraphic處理CTO病變時(shí)常用導(dǎo)絲超滑導(dǎo)絲96h處理CTO病變時(shí)常用導(dǎo)絲超滑導(dǎo)絲20hSCIMEDPT297hSCIMEDPT221hThecombinationofapolymercoverandhydrophiliccoatingprovidesoutstandinglubricity.98hThecombinationofapolymercSCIMEDPTGraphicIntermediate

Uni-bodycorewithlong,smoothtaperfromsupportregiontotipHydrophilic-coated,polymersleeveandtipIntermediatewirewithslightlystiffertipCrossingperformanceofpolymertipwithvisibilityofspringtip99hSCIMEDPTGraphicIntermediateTerumoCrossNT100hTerumoCrossNT24hWHISPER?RedefinesPolymerWirePerformanceResponsEase?grindtechnologyDURASTEEL?corematerialPolymerCoated/HydrocoatDistalsegmentSofttipdesignedforfrontlineuse101hWHISPER?RedefinesPolymerWirHI-TORQUEPILOT?Design102hHI-TORQUEPILOT?Design26hHI-TORQUEPILOT?FamilyProductDescriptionDesignHighlights: ?Polymer-tip,hydrophilic ?Core-to-tipwithmoderatesupport ?Graduatedtipstiffnessinthefamily ?ModifiedRESPONSEASE?parabolicgrind ?DURASTEEL?corematerial ?Singlelesionmeasurementmarker103hHI-TORQUEPILOT?FamilyProducTheHI-TORQUEPILOT?familyofguidewiresoffersachoiceofwiresthatvaryintipstiffnesstoaddressawidevarietyoflesionmorphology.Tipcoilsbeneaththepolymerhelpfacilitatetipshaping.104hTheHI-TORQUEPILOT?familyofModifiedRESPONSEASE?ParabolicGrindThismodifiedRESPONSEASE?designprovidesadditionalsupport,excellenttorquetransmissionandin-lesiontipcontrol.105hModifiedRESPONSEASE?ParaboliTheHI-TORQUEPILOT?guidewiresmaintainedtheirtipshapebetterthancompetitivewiresafterpassingthrough

atortuouspathmodel.TheDURASTEEL?corematerialoftheHI-TORQUEPILOT?familyisstrongerthanconventionalstainlesssteelforimprovedcorestrengthandtipshaperetention.DURASTEEL?withstandsmorepullingforcethanregular304vstainlesssteel.106hTheHI-TORQUEPILOT?guidewir.007”CorewireSupportPTFE噴涂–近端黑色的PTFE袖套延伸至遠(yuǎn)端頭部平的顯影線圈Shinobi&ShinobiPlus.010”CorewiresupportSHINOBIPlusSHINOBIWIZDOM的核心鋼絲STABILIZERPlus的核心鋼絲107h.007”CorewireSupportPTFE噴涂處理CTO病變時(shí)常用的導(dǎo)絲Coil型導(dǎo)絲108h處理CTO病變時(shí)常用的導(dǎo)絲Coil型導(dǎo)絲32hACSIntermediate&Standard?Intermediate：中軟纏繞頭端，core-to-tip，錐行漸變的中間軸?Standard：標(biāo)準(zhǔn)纏繞頭端，不易扭曲的推送桿109hACSIntermediate&Standard?ACS導(dǎo)絲110hACS導(dǎo)絲34hAGuidetoACSHI-TORQUEGuideWires111hAGuidetoACSHI-TORQUEGuideCrossIT112hCrossIT36hCrossIT

100-400113hCrossIT

100-40037hCrossIT特性114hCrossIT特性38hSmoothShaftwithFluororesincoatingJointlessSpringCoilPropertyofASAHINEO’S

PTCAGUIDEWIREFamilyWiththeunibodycorewhichispreciselytapereduptotheextremeend,withoutadditionalribbon,thushighlygoodtorqueabilityisachieved.Shafthasfluororesincoating,whichprovideshighoperativityandgoodmatchingwithballooncatheter.OnePieceCoreWireJointlessspringcoilmadeoftwodifferentmetalsprovidesgoodtorqueabilityandexcellentslidepropertywithdevicesMedicalGradeSiliconeCoating115hSmoothShaftwithFluororesinJointlessSpringCoilstructureimage

ASAHIJointlessspringcoil2-coil-connectedstructure

Jointlessstructureenablesverysmoothcurvingbentofthecoil/guidewireintortuousvessel.While,2-coil-bittenconnectioncoilmaymakesquarebent.Soldering116hJointlessSpringCoilstructuSoft/SoftAG141000Radio-opacity3cmCoil30cmDiameter0.014inchLength175cmFlexibilitySupportMoreMoreLessThisisafirstchoiceguidewirewithhightorqueresponseandexcellentsteerabilitybecauseoftheuniquecoreproperty.（Tipload0.7G）Intermediate/MediumAG142000Radio-opacity3cmCoil30cmDiameter0.014inchLength175cmFlexibilitySupportMoreMoreLessThisisaguidewirewithagoodbalanceoftipflexibilityandsupportperformance.（Tipload3.0G）Standard/StandardAG143000Radio-opacity3cmCoil30cmDiameter0.014inchLength175cmFlexibilitySupportMoreMoreLessImprovedtipstiffnesswithouruniquecoretaperdesign.（Tipload6.5G）Light/LightAG145000Radio-opacity3cmCoil20cmDiameter0.014inchLength175cmASAHINEO’SPTCAGuideWireLine-upImprovedlubricityandgoodtipshapememorywithouruniquecoredesign.Excellenttorqueresponse.Thiswirehasaflexibletipandcanbeusedasafirstchoicewireforalmostallprocedures.（Tipload0.5G）SupportFlexibilityMoreMoreLess117hSoft/SoftFlexibilitySupportM（Tipload3.0G）Miracle4.5/Miraclebros4.5AG14M045Radio-opacity11cmCoil11cmDiameter0.014inchLength175cmFlexibilitySupportMoreMoreLess（Tipload4.5G）Miracle6/Miraclebros6AG14M060Radio-opacity11cmCoil11cmDiameter0.014inchLength175cmFlexibilitySupportMoreMoreLess（Tipload6.0G）Miracle12/Miraclebros12AG14M070Radio-opacity11cmCoil11cmDiameter0.014inchLength175cmFlexibilitySupportMoreMoreLow（Tipload12.0G）Miracle3/Miraclebros3AG14M050Radio-opacity11cmCoil11cmDiameter0.014inchLength175cmMiracleSeriesApplyingthestructurewhichfurtherimprovestorqueperformanceforCTOuse.Thetipparthasthestructurewhichisdifficulttobetrappedbythelesions.FlexibilitySupportMoreMoreLess118h（Tipload3.0G）Miracle4.5/MiStructureofConquestPro/Pro12

0.014”200mmRadiopaqueSpringCoil0.009”StainlessCoreWirePTFECoatingHydrophilicCoatingAGH143090ConquestPro119hStructureofConquestPro/Pro1GrandSlam/GrandSlam

AG141002Radio-opacity4cmCoil4cmDiameter0.014inchLength175cmFlexibilitySupportMoreMoreLessInspiteofitsflexibletip,thecoreisalsodesignedtoprovidestrongsupportwhenapproachingthetortuouslesions.（Tipload0.7G）MarkerWireAG141010Radio-opacity3cmCoil30cmDiameter0.014inchLength175cmFlexibilitySupportMoreMoreLessSameleveloftipstiffnessasSOFT.Ithastenmarkersstartingafter50mmfromthetiptoscalelesionsandpositiondevices.（Tipload0.7G）Rinato/ProwaterAG146000Radio-opacity3cmCoil20cmDiameter0.014inchLength175cmCONQUEST/ConfianzaAG143090Radio-opacity20cmCoil20cmDiameter0.014inchLength175cmThiswireisdevelopedforCTOuse.HigherpenetrationabilitythanMiracles.Diameteroftipcoilistaperedto0.009inch(φ0.23mm).（Tipload9.0G）FlexibilitySupportMoreMoreLessHydrophiliccoatingoverthecoilspring(after3cmfromthetip).NewlydesignedoriginalcoreshaftgivesadequatelyhighersupportperformancethanSOFT,improvedtorqueperformance.（Tipload0.8G）FlexibilitySupportMoreMoreLess120hGrandSlam/GrandSlamFlexib121h45h122h46h如何選擇導(dǎo)絲123h如何選擇導(dǎo)絲47h

下列情況首選超滑涂層的導(dǎo)絲1.閉塞段近端無邊支開口，病變長(zhǎng)度<20mm，血管殘端程鼠尾狀狀。鼠尾狀124h下列情況首選超滑涂層的導(dǎo)絲1.閉塞段近端無邊支開口，病變下列情況首選超滑涂層的導(dǎo)絲2.閉塞段有彎曲的閉塞段扭曲125h下列情況首選超滑涂層的導(dǎo)絲2.閉塞段有彎曲的閉塞段扭曲49下列情況首選超滑涂層的導(dǎo)絲3.閉塞段近端及遠(yuǎn)端彎曲重的近端過度扭曲遠(yuǎn)端過度扭曲126h下列情況首選超滑涂層的導(dǎo)絲3.閉塞段近端及遠(yuǎn)端彎曲重的近端下列情況首選尖端纏繞形導(dǎo)絲1.血管殘端呈齊頭的2.閉塞段近端有分支開口的齊頭閉塞127h下列情況首選尖端纏繞形導(dǎo)絲1.血管殘端呈齊頭的齊頭閉塞51下列情況首選尖端纏繞形導(dǎo)絲3.閉塞段長(zhǎng)度>20mm4.閉塞時(shí)間>6個(gè)月128h下列情況首選尖端纏繞形導(dǎo)絲3.閉塞段長(zhǎng)度>20mm52h導(dǎo)絲通過閉塞段時(shí)的情況1.導(dǎo)絲通過閉塞1-6個(gè)月內(nèi)、長(zhǎng)度<20mm沒有鈣化的病變時(shí)較順利，成功率高。129h導(dǎo)絲通過閉塞段時(shí)的情況1.導(dǎo)絲通過閉塞1-6個(gè)月內(nèi)、長(zhǎng)度<導(dǎo)絲通過閉塞段時(shí)的情況2.導(dǎo)絲通過有硬核的閉塞段時(shí)導(dǎo)絲無法穿透斑塊，其尖端沿斑塊邊緣穿透血管壁導(dǎo)絲強(qiáng)行穿過硬斑塊核130h導(dǎo)絲通過閉塞段時(shí)的情況2.導(dǎo)絲通過有硬核的閉塞段時(shí)導(dǎo)絲無法如何判斷導(dǎo)絲是否在真腔1.根據(jù)不同的投照角度131h如何判斷導(dǎo)絲是否在真腔1.根據(jù)不同的投照角度55h如何判斷導(dǎo)絲是否在真腔2.根據(jù)導(dǎo)絲尖端的形態(tài)和走性真腔中導(dǎo)絲尖端彎形“J”存在，導(dǎo)絲可自由旋轉(zhuǎn)，可沿主支血管走形前進(jìn)，也能進(jìn)入相應(yīng)分支，并每次均能規(guī)律進(jìn)入同一走行分支。132h如何判斷導(dǎo)絲是否在真腔2.根據(jù)導(dǎo)絲尖端的形態(tài)和走性56h如何判斷導(dǎo)絲是否在真腔3.通過側(cè)支循環(huán)顯示閉塞段遠(yuǎn)端造影通過逆行或順行側(cè)支顯示閉塞段遠(yuǎn)端，多角度透射觀察導(dǎo)絲是否在真腔；在導(dǎo)絲即將通過閉塞段進(jìn)入閉塞段遠(yuǎn)端血管真腔時(shí)尤應(yīng)謹(jǐn)慎，導(dǎo)絲每前進(jìn)1-2mm就應(yīng)多角度投照，調(diào)整導(dǎo)絲尖端方向，防止損傷閉塞段遠(yuǎn)端血管，造成長(zhǎng)夾層而不可修復(fù)。133h如何判斷導(dǎo)絲是否在真腔3.通過側(cè)支循環(huán)顯示閉塞段遠(yuǎn)端57h如何判斷導(dǎo)絲是否在真腔4.通過OTW球囊造影判斷一旦導(dǎo)絲在假腔，造影時(shí)造影劑沖擊損傷血管內(nèi)膜，形成全程長(zhǎng)夾層，導(dǎo)絲無法在進(jìn)真腔，并造成遠(yuǎn)端血管閉塞－－心梗。

此法很少用.134h如何判斷導(dǎo)絲是否在真腔4.通過OTW球囊造影判斷導(dǎo)絲成形及操作技巧135h導(dǎo)絲成形及操作技巧59hCTO病變導(dǎo)絲尖端成形半徑要小成形半徑大，則前向力被分解，導(dǎo)絲不易前行成形半徑大，對(duì)血管壁損傷大成形半徑大，不易調(diào)整方向136hCTO病變導(dǎo)絲尖端成形半徑要小成形半徑大，則前向力被分解，導(dǎo)閉塞段近端成角大的病變要先將導(dǎo)絲頭端塑形成較大的角度，使其易于通過閉塞段近端的扭曲，并將微導(dǎo)管或OTW球囊導(dǎo)入到病變處；再將導(dǎo)絲重新塑形成小角度或換用塑形成小角度硬導(dǎo)絲，嘗試通過病變。137h閉塞段近端成角大的病變要先將導(dǎo)絲頭端塑形成較大的角度，使其易閉塞段較硬的病變對(duì)于較硬的病變估計(jì)球囊不易通過者，除在導(dǎo)絲頭端塑形成角后，可在導(dǎo)絲尖端再塑形第二個(gè)小角（只適用于CrossIT300-400、ConquestPro9-12及Miracle9-12），將閉塞病變“掏”大，但導(dǎo)絲旋轉(zhuǎn)速度不能快。138h閉塞段較硬的病變對(duì)于較硬的病變估計(jì)球囊不易通過者，除在導(dǎo)絲頭139h63hCTO病變的支架選擇140hCTO病變的支架選擇64hCTO病變中PTCA和支架植入術(shù)比較：再狹窄發(fā)生率141hCTO病變中PTCA和支架植入術(shù)比較：再狹窄發(fā)生率65hCTO病變中PTCA和支架植入術(shù)比較：再閉塞發(fā)生率142hCTO病變中PTCA和支架植入術(shù)比較：再閉塞發(fā)生率66h相對(duì)于單純PTCA術(shù)，金屬裸支架降低了再狹窄和再閉塞率，但仍然比較高．與金屬裸支架相比雷帕霉素藥物支架明顯降低了低或中危再狹窄風(fēng)險(xiǎn)病人的晚期管腔丟失和再狹窄率

143h相對(duì)于單純PTCA術(shù)，金屬裸支架降低了再狹窄和再閉塞率，但仍CTO中應(yīng)用CYPHERstent的經(jīng)驗(yàn)HoyeA.,etal.,JAmCollCardiol2004;43(11):1954-8.-56例CYPHER治療GeL.,etal.,EurHeartJ2005:26(11):1056-62-122例CYPHER治療NakamuraS.,etal.,AmJCardiol2005;95:161-6-60例CYPHER治療TheSICTOSt