复杂冠脉分叉病变的pci治疗策略

PCI Strategies for Complex Coronary Bifurcation lesions 首都医科大学附属北京安贞医院 周玉杰 聂斌 Beijing Anzhen Hospital One or two stents? Nordic Bifurcation Study (n=413) 413 pts with bifurcation lesion Stenting of the main vessel and side branch (MV+SB) Stenting of the main vessel and optional stenting of the side branch (MV) n=206 n=207 Randomized Primary Endpoint: Major adverse cardiac event (MACE) at 6 months Primary Endpoint of MACE at 6 months (%) p=NS Presented at ACC 2006 There was no difference in major adverse cardiac events at 6 months (17.7% vs 12.7%; p=NS) Nordic Bifurcation Study (n=413) Procedure related MI was defined as a five-fold elevation of biochemical markers Procedure related MI occurred more than three times as often in the MV+SB group (13% vs 4%; p=0.008) Procedure Related Myocardial Infarction (%) p=0.008 Presented at ACC 2006 Nordic Bifurcation Study (n=413) One Stent Strategy Provisional T Stenting Provisional T Stent Provision-T stent technique 53 pts, SB2mm MACE 9.4% at 14+/-3 months TLR 3.8%, MV restensosis 3.2%, SB 12.9% at 6 months Vigna C, et al. J Invasive Cardiol. 2007 Mar;19(3):92-7. p The SB has a narrowing at its ostium p The MB has severe stenosis with a large plaque burden and the SB originates with an angle of 45 p The ostium of the SB deteriorates after pre- dilatation of the MB A wire is needed in the following circumstances: Provisional T Stent FKB is Very Important for Provisional T Stent Provisional T Stent Two Stents Techniques l T stent l Culotte l SKS l V stent l Provisional T l Modified T stent l Y stent BMS Era DES Era Crush Reverse Crush Balloon Crush DK Crush Mini-Crush Inverted Crush T stent Technique Culotte Technique Clinical Outcomes p In BMS era, the incidence of TLR was 24% at 6 months (Chevalier. Am J Cardiol 1998;82:943) p In DES era, the incidence of MACE was 5.3% and TLR was 15.4% (Hoye, et al. Int J Cardiovasc interven 2005;7:36) Culotte vs T stent in DES era 80 patients with bifurcation lesions Culotte technique 45 cases T stent 35 cases The procedural success rate 100% TLR: 8.9% P = 0.014 ;9months MACE 13.3% P=0.051 Kaplan S, et al. Am Heart J. 2007 Aug;154(2):336-43 The procedural success rate 100% TLR: 27.3% 9months MACE 27.3% SKS Technique Clinical Outcome 200 patients with bifurcation lesions SKS technique Cypher stents The clinical success rate is 97% The incidence of TLR: 4% 9+/- 2 months Sharma SK. Catheterization and Cardiovascular Interventions 2005;65:10 Clinical Outcome 36 patients with bifurcation lesions SKS technique SES stents 26.7+/-8.6 month The procedure success rate is 100% No MACE, MB restenosis13%, SB 10% The incidence of TLR: 14%, Kim YH, et al. Catheter Cardiovasc Interv. 2007 Nov 15;70(6):840-6 Y Stent Technique Crush Technique Clinical Outcomes pThe survival rate free of TLR was 90.3%, incidence of restenosis at MB was 9.1%, restenosis at SB was 25.3% (Hoye A . J Am Coll Cardiol 2006;47:1949-1958 ) p Incidence of TLR at 6 month follow-up is 11.3% (Moussa I Am J Cardiol 2006； 97： 1317 1321) Colombo et al. PCR 2004 Final Kissing is very important ! Step 1: Wire both branches and predilate both Step 2: Both stents in place. Side-branch stent positioned more proximal Inverted Crush Wire both branches and predilate Deploy stent in main branch Reverse crushing technique Wire side branch and dilate Position stent in side branch protruding in MB (slight), leave a balloon in MB Deploy stent in the side branch and remove wire and balloon Crush the protruding part of SB on top of the stent in MB Balloon Crush DK Crush ( Sleeve Technique) mini-crush 45 pts, 52lesions Procedural success 100% No in-hospital MACE TLR 12.2%, MV restensosis 12.2%, SB 2% at 8 months Galassi AR, et al. Catheter Cardiovasc Interv. 2007 1;69(7):976-83 TAP technique Wire both branches and predilate Deploy stent in main branch Wire side branch and dilate Kissing balloon SB stent positioning SB stent is deployed with the uninflated balloon into the MV The balloon of the SB stent is slightly retrieved and aligned to the MV balloon Final kissing balloon In vitro TAP stenting Perfect coverage of the bifurcation with minimal stents struts overlap at the proximal part of SB ostium 0.070” 0.071 0.078” 6F 7F 5.3F 5.4F 5.9F Tips and tricks Size of Guiding Catheter MV balloon shaft profile + SB stent shaft profile 8F 6.0F 0.088” 6 F 7 F 8 FGC 球囊种类 （ 3.5mm) 推送杆外径 Maverick 2 2.0F Ryujin 2.5F SeQuent 2.5F Avita 2.55F Sprinter 2.6F Crosssail 2.6F Kingou 2.6F Aqua T3 2.7F Powersail 2.9F AVION Extensor Voyager Grip CTO 2.8F 3.0 2.7 2.6 2.5 5.4F 0.070 5.3F 6F导管完成对吻扩张 6F导引导管的内径： 0.070 0.071) 两球囊推送杆 外径之和 应 5.3F 6F导引导管进行球囊对吻技术 球囊外径： 2.9F+2.6F=5.5F 6F导管内径： 0.070 inch 5.4F 选用 导引导管： 6F JL 3.5 Case of TAP stenting Coronary Angiography 6F EBU 3.5 BMW BMW 3.024mm Cypher Deployment MV stent with jailed guidewire into the SB Kissing balloon after rewiring of SB SB stent positioning SB stent MV balloon The position of the SB stent is adjusted to fully cover the proximal part of the SB ostium (red arrow) while an uninflated balloon kept into the MV SB is deployed with the uninflated balloon into MV SB stent deployment Final kissing balloon The balloon of the SB stent is slightly retrieved and aligned to the MV balloon Final kissing balloon SB stents balloon MV balloon Final Result Clinical study of TAP Burzotta F, et al. Catheterization and Cardiovascular Interventions 2007, 70:7582 Angiographic characteristics Target lesion n=61 Distal LM 26 LAD/diagonal 28 LCX/OM 5 RCA/descending posterior 2 Angulation between main and side-branch Angle 70 36 Angle 70 26 Approach Transradial 24 Transfemoral 37 Guiding catheter size 6 Fr 2 7 Fr 25 8 Fr 34 Procedure time 11252min Procedure characteristics Clinical outcome (9 month) MACE 4 (6.6%) Death 1 (1.6%) Myocardial infarction 0 TLR 3 (4.9%) Stent thrombosis Definited 1 (1.6%) Suspected 1 (1.6%) Patients without MACE 56 (91.8%) Strategies for LMCA