基礎(chǔ)醫(yī)學(xué)CTO病變的技巧冠心病進展

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CTO介入的導(dǎo)絲選擇CTO病變的支架選擇CTO的定義閉塞時間大于3個月的病變CTO病變形成時間的判斷AMI的時間病癥加重的時間側(cè)枝循環(huán)形成的多少及側(cè)枝的直徑CTO病變長度的判斷順行顯影逆行顯影雙向造影順行顯影逆行顯影CTO病變的病理結(jié)構(gòu)1.壞死脂核、膽固醇結(jié)晶及鈣化CTO病變的病理結(jié)構(gòu)2.細胞外基質(zhì)：膠原、鈣化CTO病變的病理結(jié)構(gòu)3.微血管CTO病變的類型重度狹窄慢性閉塞輕中度狹窄慢性閉塞重度狹窄慢性閉塞?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，閉塞時間一般為3個月以上，重塑的組織中含有大量的纖維組織?長閉塞段：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%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，未及時治療，導(dǎo)致血管慢性閉塞，新的閉塞處遠離原有狹窄斑塊，導(dǎo)絲注意尋找閉塞斑塊CTO病變的病理特點粥樣斑塊+鈣化慢性開展融合而成CTO病變的病理特點斑塊破潰形成血栓機化而成CTO介入的導(dǎo)絲選擇導(dǎo)絲的結(jié)構(gòu)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方式?支持力：中心鋼絲的直徑和材料處理CTO病變時常用的導(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等處理CTO病變時常用導(dǎo)絲超滑導(dǎo)絲SCIMEDPT2Thecombinationofapolymercoverandhydrophiliccoatingprovidesoutstandinglubricity.SCIMEDPTGraphicIntermediate

Uni-bodycorewithlong,smoothtaperfromsupportregiontotipHydrophilic-coated,polymersleeveandtipIntermediatewirewithslightlystiffertipCrossingperformanceofpolymertipwithvisibilityofspringtipTerumoCrossNTWHISPER?RedefinesPolymerWirePerformanceResponsEase?grindtechnologyDURASTEEL?corematerialPolymerCoated/HydrocoatDistalsegmentSofttipdesignedforfrontlineuseHI-TORQUEPILOT?DesignHI-TORQUEPILOT?FamilyProductDescriptionDesignHighlights: ?Polymer-tip,hydrophilic ?Core-to-tipwithmoderatesupport ?Graduatedtipstiffnessinthefamily ?ModifiedRESPONSEASE?parabolicgrind ?DURASTEEL?corematerial ?SinglelesionmeasurementmarkerTheHI-TORQUEPILOT?familyofguidewiresoffersachoiceofwiresthatvaryintipstiffnesstoaddressawidevarietyoflesionmorphology.Tipcoilsbeneaththepolymerhelpfacilitatetipshaping.ModifiedRESPONSEASE?ParabolicGrindThismodifiedRESPONSEASE?designprovidesadditionalsupport,excellenttorquetransmissionandin-lesiontipcontrol.TheHI-TORQUEPILOT?guidewiresmaintainedtheirtipshapebetterthancompetitivewiresafterpassingthrough

atortuouspathmodel.TheDURASTEEL?corematerialoftheHI-TORQUEPILOT?familyisstrongerthanconventionalstainlesssteelforimprovedcorestrengthandtipshaperetention.DURASTEEL?withstandsmorepullingforcethanregular304vstainlesssteel..007〞CorewireSupportPTFE噴涂–近端黑色的PTFE袖套延伸至遠端頭部平的顯影線圈Shinobi&ShinobiPlus.010〞CorewiresupportSHINOBIPlusSHINOBIWIZDOM的核心鋼絲STABILIZERPlus的核心鋼絲處理CTO病變時常用的導(dǎo)絲Coil型導(dǎo)絲ACSIntermediate&Standard?Intermediate：中軟纏繞頭端，core-to-tip，錐行漸變的中間軸?Standard：標準纏繞頭端，不易扭曲的推送桿ACS導(dǎo)絲AGuidetoACSHI-TORQUEGuideWiresCrossITCrossIT

100-400CrossIT特性SmoothShaftwithFluororesincoatingJointlessSpringCoilPropertyofASAHINEO’S

PTCAGUIDEWIREFamily

Withtheunibodycorewhichispreciselytapereduptotheextremeend,withoutadditionalribbon,thushighlygoodtorqueabilityisachieved.Shafthasfluororesincoating,whichprovideshighoperativityandgoodmatchingwithballooncatheter.OnePieceCoreWireJointlessspringcoilmadeoftwodifferentmetalsprovidesgoodtorqueabilityandexcellentslidepropertywithdevicesMedicalGradeSiliconeCoatingJointlessSpringCoilstructureimage

ASAHIJointlessspringcoil2-coil-connectedstructure

Jointlessstructureenablesverysmoothcurvingbentofthecoil/guidewireintortuousvessel.While,2-coil-bittenconnectioncoilmaymakesquarebent.SolderingSoft/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〕SupportFlexibilityMoreMoreLess〔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.FlexibilitySupportMoreMoreLessStructureofConquestPro/Pro12

0.014”200mmRadiopaqueSpringCoil0.009”StainlessCoreWirePTFECoatingHydrophilicCoatingAGH143090ConquestProGrandSlam/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〕FlexibilitySupportMoreMoreLess如何選擇導(dǎo)絲以下情況首選超滑涂層的導(dǎo)絲1.閉塞段近端無邊支開口，病變長度<20mm，血管殘端程鼠尾狀狀。鼠尾狀以下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以下情況首選超滑涂層的導(dǎo)絲3.閉塞段近端及遠端彎曲重的近端過度扭曲遠端過度扭曲以下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以下情況首選尖端纏繞形導(dǎo)絲3.閉塞段長度>20mm4.閉塞時間>6個月導(dǎo)絲通過閉塞段時的情況1.導(dǎo)絲通過閉塞1-6個月內(nèi)、長度<20mm沒有鈣化的病變時較順利，成功率高。導(dǎo)絲通過閉塞段時的情況2.導(dǎo)絲通過有硬核的閉塞段時導(dǎo)絲無法穿透斑塊，其尖端沿斑塊邊緣穿透血管壁導(dǎo)絲強行穿過硬斑塊核如何判斷導(dǎo)絲是否在真腔1.根據(jù)不同的投照角度如何判斷導(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，也能進入相應(yīng)分支，并每次均能規(guī)律進入同一走行分支。如何判斷導(dǎo)絲是否在真腔3.通過側(cè)支循環(huán)顯示閉塞段遠端造影通過逆行或順行側(cè)支顯示閉塞段遠端，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入閉塞段遠端血管真腔時尤應(yīng)謹慎，導(dǎo)絲每前進1-2mm就應(yīng)多角度投照，調(diào)整導(dǎo)絲尖端方向，防止損傷閉塞段遠端血管，造成長夾層而不可修復(fù)。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，造影時造影劑沖擊損傷血管內(nèi)膜，形成全程長夾層，導(dǎo)絲無法在進真腔，并造成遠端血管閉塞－－心梗。

此法很少用.導(dǎo)絲成形及操作技巧CTO病變導(dǎo)絲尖端成形半徑要小成形半徑大，那么前向力被分解，導(dǎo)絲不易前行成形半徑大，對血管壁損傷大成形半徑大，不易調(diào)整方向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。閉塞段較硬的病變對于較硬的病變估計球囊不易通過者，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。CTO病變的支架選擇CTO病變中PTCA和支架植入術(shù)比較：再狹窄發(fā)生率CTO病變中PTCA和支架植入術(shù)比較：再閉塞發(fā)生率相對于單純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)險病人的晚期管腔喪失和再狹窄率

CTO中應(yīng)用CYPHERstent的經(jīng)驗HoyeA.,etal.,JAmColl

Cardiol2004;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

SICTOSTUDYDESIGNAmulticenter,prospective,non-randomizedstudytoassessthefeasibilityandrestenosis/reocclusionratesofcoronarystentingwiththeCypherTMSirolimus-elutingstentinpatientswithchronictotalocclusion

25patientsweretreatedwiththeCypherTMSirolimus-elutingstentaftersuccessfulballoonangioplastyandIVUSexamination.

Clinicalfollow-upat30days,6,12,18and24months-repeatangiographyandIVUSat6monthsfollow-up.SICTO

–ConclusionInthisfeasibilitystudytheCYPHERTMSirolimus-eluting

stentwasveryeffectiveinthetreatmentofCTO,withvery

lowratesofTLR(0%),MACE(0%)andTVR(8%)

comparedtohistoricaldatawithbarestents(30-50%).TheCYPHERTMSirolimus-elutingstentsignificantlyinhibitsintimalhyperplasiainCTO.ThesepreliminarydatawillcomeinadditionoflargerdatabasewithCTOsubpopulation(e.g.e-Cypher)

PRISONIIStudyTocomparetheimmediateandlong-termangiographicandclinicalresultsofBMS(BxVelocity?