冠脈分叉病變不同介入治療策略評價

冠脈分叉病變不同介入治療策略評價阜外心血管病醫(yī)院楊偉憲2010-7-242010-7Accountfor15-20%ofPCIWhyanindivdualizedapproach?VariationsinAnatomyLeftmainbifurcationdiseasePlaqueburden&locationofplaqueAnglebetweenMBandSBDynamicchangesinanatomyduringtreatmentPlaqueshiftDissection

NotwobifurcationsareidenticalAnappropriatestrategyfromtheoutsetsavestimeandminimizescomplicationBifurcationPCI分叉病變分型DukeClassificationSanbornClassificationIakovouI,GeL,ColomboA.JACC,2005;46:1446-1455.SafianClassificationIakovouI,GeL,ColomboA.JACC,2005;46:1446-1455.LefevreClassificationIakovouI,GeL,ColomboA.JACC,2005;46:1446-1455.MedinaClassificationMedinaetal.RevEspCardiol.2006;59(2):183-4.分叉病變介入治療策略單支架二個支架單個支架或二個支架?A)如果分支血管的開口部位或其附近有明顯的病變，其血管直徑足夠大，從安全性和PCI的療效來考慮應(yīng)該置入兩個支架。B)在其他情況下，應(yīng)置入一個支架andthenevaluate當前，大家公認和使用的分叉病變治療策略是分支血

管Provisional支架術(shù)。然而仍有許多分支血管其解剖結(jié)構(gòu)（直徑較大，病變較為彌漫）需要置入兩個支架。

WhatTypeofBifurcationsare

CommonlyTreated?Majority(65%)are“True”bifurcationsExtentofSBdiseasemaydeterminestrategyNon-LMBifstreatedinMilan(n=320).ExtentofSBdisease:0 18%<5mm 27%5-10mm 19%>10mm 36%分叉病變介入治療技術(shù)分支血管通暢技術(shù)(KIO)必要時置入第二個支架（Provisional2ndstent）雙支架術(shù)分支血管通暢技術(shù)(KIO)當分支血管開口病變或彌漫性病變，并且分支血管不適合置入支架時（太細?。┗蛘叻种а芎团R床癥狀不相關(guān)時主支和分支血管分別放入導(dǎo)引鋼絲如果需要擴張主支血管主支血管置入支架，分支血管保留導(dǎo)引鋼絲后擴張主支血管，分支血管保留受壓的導(dǎo)引鋼絲不要再次把導(dǎo)引鋼絲放入分支血管或者后擴張或預(yù)擴張分支血管

Provisional支架當分支血管病變程度極輕或者病變僅位于分支血管開口處并且分支血管解剖結(jié)構(gòu)適合置入支架者主支和分支血管放入導(dǎo)引鋼絲擴張主支血管，必要時擴張分支血管主支血管置入支架，分支血管保留導(dǎo)引鋼絲分支血管再次放入導(dǎo)引鋼絲，然后撤出受壓的原導(dǎo)引鋼絲球囊對吻如果分支血管出現(xiàn)次佳結(jié)果則在分支血管置入支架（T支架術(shù)或ReverseCrush）保護分支血管術(shù)前冠脈造影前降支－對角支病變前降支置入支架Xience3.0x28mm支架術(shù)后對角支POBA球囊3.0x20mm前降支－對角支病變最終結(jié)果Wirebothbranchesandpre-dilatethemainandthesidebranchasrequired.Step1:StenttheMBjailingtheSBwireIftheresultinSBunsatisfactoryduetoplaqueshiftordissectionandSBhastobestented,thenre-crossintotheSBthroughtheMBstentstrutsStep2:TheT-stentingwithProtrusionTechnique(TAP)asaCross-overfromthe

ProvisionalApproachPositionstentinSBensuringcoverageofostiumwithminimalprotrusionintoMBandplacenon-compliantballooninMBstentFinalResult:InflatethedeliveryballoonintheSBandtheMBballoonsimultaneouslyStep3:Step4:TheT-stentingwithProtrusionTechnique(TAP)asaCross-overfromthe

ProvisionalApproach1:RewiresidebranchandadvanceaballoonanddilatetowardSB2:PositionastentintheSBwithminimalprotrusionintheMB.LeaveaballoonintheMBEVALUATERESULT:iftheresultisnotacceptablethenAReverseCrushStenting3:DeploythestentintheSBandremovethewireandtheballoon4:CrushtheshortprotrudingpartofSBstentoverthestentinMBbyinflatingtheMBballoonBReverseCrushStenting5:RewiretheSBandperformhighpressuredilatation6:PerformfinalkissingballooninflationCReverseCrushStenting雙支架術(shù)當分支血管的病變比較彌漫，不僅僅局限于分支開口部位，并且分支血管適合置入支架主支和分支血管放入導(dǎo)引鋼絲擴張主支血管，必要時擴張分支血管Crush支架術(shù)或其他雙支架術(shù)如果進行Crush:分支血管再次放入導(dǎo)引鋼絲,對其進行高壓球囊擴張球囊對吻擴張Crush支架術(shù)標準Crush：7F以上指引導(dǎo)管,事先對兩個支架定位，然后釋放分支血管支架，主支血管支架擠壓分支血管支架Reverse（Internal）Crush：行Provisional支架術(shù)時需要在分支血管置入另一個支架時采用。6F指引導(dǎo)管，首先釋放主支血管支架，通過主支支架的側(cè)孔置入分支血管支架，通過預(yù)留在主支的球囊對分支血管支架進行擠壓InverseCrush：

操作過程類似標準Crush支架術(shù)，但是分支血管的支架定位比主支血管更為近端，分支血管的支架去擠壓主支血管支架StepCrush：與標準Crush技術(shù)相同，但可在6F指引導(dǎo)管進行StentingTechniquesfortheTreatmentBifurcationLesionsLouvardY,LefevreT,MoriceMC,etal,Heart2004;90:713-22ClassicTbeginningSBModifiedTCrushClassicTbeginningMBProvisionTCullotteTouchingstentsTrouserlegsandseatKissingstentsSkirttechnique分叉病變包括左主干病變的治療方法真性分叉病變(主支和分支血管明顯狹窄)非是主支血管置入支架，分支血管進行球囊擴張

分支血管適合支架術(shù)分支血管病變，從開口向遠端彌漫超過3mm以上選擇性置入兩個支架（主支和分支）分支血管Provisional支架術(shù)分支血管Provisional支架術(shù)或KIO非是非是絕大多數(shù)分叉病變在介入治療結(jié)束時需要保持分支血管通暢，殘余狹窄似乎意義不大如果分支血管達到最佳結(jié)果比較重要，在真性分叉病變中至少有50％的患者需要置入兩個支架分叉病變總結(jié)1支架策略

只有臨床需要才進行冠脈造影隨訪BMSera:Onestentisbetter!%TVREnd-pointat6months(%)p=NSNORDICBifurcationStudySteigenTKetal.Cir,2006,114:1955-61.MACEat6months（%）p=NSNORDICBifurcationStudySteigenTKetal.Cir,2006,114:1955-61.MIrelatedtotheprocedure(％)p=0.008NORDICBifurcationStudySteigenTKetal.Cir,2006,114:1955-61.StentThrombosis(%)p=NSNORDICBifurcationStudySteigenTKetal.Cir,2006,114:1955-61.NordicStentTechniqueStudyARandomizedStudyofCrushvs.CulotteStentTechniqueswithSirolimusElutingStentsinBifurcationLesionsErglisAetal.CircCardiovascIntervent,2009;2:27-34Crush(n=209)Culotte(n=215)Pvalue

MACE4.3%3.7%0.87Procedure-relatedBio-markersincrease15.5%8.8%0.08InsegmentRestenosis12.1%6.6%0.10InstentRestenosis10.5%4.5%0.046NordicII:NordicIII:AProspectiveRandomizedTrialofSideBranchDilatationStrategiesinPatientswithCoronaryBifurcationLesionsUndergoingTreatmentwithaSingleStentNOKISSINGKISSING%2.92.9PrimaryendpointMACE(cardiacdeath,indexlesionMI,TLR,stentthrombosis)after6monthsnsNiemelaM.TCT2009BBCONEStudy

PRIMARYENDPOINT

Composite(9months)Death,MI,TVFSimpleComplexPvalue

Death0.4%0.8%-

Myocardialinfarction3.6%11.2%0.001

Targetvesselfailure5.6%7.2%0.43

Primaryendpoint8.0%15.2%0.009HR2.02(1.17to3.47)DavidHildick-Smithetal.Cir2010;121:1235-1243BBCONEStudy

PROCEDURALENDPOINTSimpleComplexPvalueProcedureTime,min5778<0.001FluoroscopyTime,min1522<0.001Diamentor,cGy-cm261407900<0.001No.ofGuidewiresUsed2.23.1<0.001No.ofBalloonUsed2.34.0<0.001No.ofStentsUsed1.22.2<0.001DavidHildick-Smithetal.Cir2010;121:1235-1243*OnenoncardiacdeathduetoischemicstrokeCACTUSStudy(CoronaryBifurcations:ApplicationoftheCrushingTechniqueUsingSirolimus-ElutingStents)ColomboA,etal.Circulation.2009;119(1):71-8EndpointCrush(%)ProvisionalT(%)Main-branchbinarystenosis4.66.7Side-branchbinaryrestenosis13.214.7MI0.50.5TLR5.65.8TVR6.26.8Death00.5*Stentthrombosis1.71.1InfluenceofFinalKissingintheCACTUStrialColomboA,etal.Circulation.2009;119(1):71-8EndpointFinalKissing(163pts)NoFinalKissing(14pts）PvalueMain-branchstenosis4.7%16%0.03Side-branchrestenosis11.9%36%0.001MI7.5%29%0.001TLR6.3%12.9%0.25Stentthrombosis0.9%6.5%0.060.60.40.2MainBranchSideBranch051015202530354015.5%(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)0.320.52ImportantRoleoffinalkissingballooninCrushTechniqueGeL,etal.JACC,2005;46:613-620.WithoutFKBFKBKissme,Kate!9MonthClinicalOutcomesAfterCrushStentingGeL,etal.JACC,2005;46:613-620.T-stenting(n=61)Crushingstenting(n=121)T-StentingVS.CrushingStenting14.0%

TLR TVR TLR TVR31.1%16.5%32.8%14.1%11.3%28.9%31.1%ENTIRECOHORT05101520253035KISSINGBALLOONP=0.01P=0.02P=0.03P=0.04GeL,etal.Heart,2006;92:371-376GeL,etal.Heart,2006;92:371-376MiniCrushwithDoubleKissingJIMMH,etal.CCI,2007,69:969-975Non-randomizedcomparison;457pati