右冠脉分叉

Jin Zening Beijing Anzhen Hospital Beijing, CHINA Male, 54 Years 3 years history of increasing exertional chest pain despite of use Aspirin， Felodipine， Losartan， Metoprolol， Atorvastatin and Isosorbide Mononitrate 11 years history of hypertension 31 years history of ongoing tobacco use No diabetes mellitus CK: 148U/L， CKMB: 7U/L Troponin： negative TG： 3.07mmol/L； TCHO： 5.41mmol/L； HDL： 0.9mmol/L； LDL-C： 3.55mmol/L BUN： 98mmol/L； Serum Creatinine： 87umol/L ECG： Non specific ST-T change UCG： EF 53%; LV 35/49 mm TCT 2005, Morice MC 1,1,1 1,1,0 1,0,1 0,1,1 1,0,0 0,1,0 0,0,1 Femoral Approach 7F Femoral Sheath Plan 7F AL 0.75 or XBRCA， but So 7F JR 3.5 Guide Wire： Cronus Moderate Support 0.014”*210cm Magnetic Navigating System 2 DES 3mm tip Diameter 2.5mm The Guide catheters backup is not strong enough, we cant advance a Cypher select 2.7533 stent to the PLA. Deep seating, Buddy wire, Using a balloon as a slide trackDoesnt work! At last, we cant even advance a balloon into distal of RCA! Change the guide catheter: 6F AL1 But the waveform damping on hemodynamic monitor, and the QRS wave of ECG becoming wide. Made a side hole on the AL1 catheter Re-cross both guide wire Crush 1.Cypher 2.7533 (16atm) 2.Cypher 2.513 (14atm) 3.Voyager 2.515 4.Cypher 3.028 (20atm) Cypher 3.028 (20atm) About 3 hours Contrast Agents: Iohexol 425ml One day after PCI: BUN:4.98mmol/L Creatinine:87umol/L ADP: 27% AA:11% Louvard Y, Lefevre T, Morice MC, et al, Heart 2004; 90: 713-22 Classic T beginning SB Modified T Crush Classic T beginning MB Provision T Cullotte Touching stents Trouser legs and seat Kissing stents Skirt technique Colombo et al (Circ 2004) Pan et al (AHJ 2004) Nordic (Circ 2006) n=91 n=413n=85 6month 6month 6month 19.0% 3.4% 10.6% 13.6% 2.9% 1.9% 6.3% 9.0% 4.5% 2.1% 1.9% 11.4%11.1% 9.0% 1.9% 9.5% 4.5% 1.0% % of Patients MACE TVR TLR 2 Stents1Stent 2 Stents1Stent 2 Stents1Stent Colombo et al (Circ 2004) Pan et al (AHJ 2004) Nordic (Circ 2006) n=91 n=413n=85 6month 6month 6month % of Bifurcations Bifurcation Main Branch Side Branch 18.7% 4.8% 14.2% 28.0% 5.7% 21.8% 7.0% 2.0% 5.0% 20.0% 15.0% 5.0% 4.6% 5.1% 22.5% 19.2% 16.0% 11.5% 2 Stents1Stent 2 Stents1Stent 2 Stents1Stent 1. If the side branch is significantly diseased at its ostium or nearby, it is sufficiently large to be stented, safety and duration of PCI are an issue: 2 stents 2. In all other conditions 1 stents and then evaluate 3. At present time the most accepted and applied strategy is provisional SB stenting Kissing Ballon No Kissing Main Branch Side Branch Crush stent T Stent Crush stent T Stent Crush stent T Stent Crush stent T Stent Crush stent T Stent Crush stent T Stent Crush stent T Stent Crush stent T Stent Restenosis (%) Lateloss (mm) 0 0.2 0.4 0.6 0.8 13.8% (8/58) 14.7% (5/34) 19.5% (8/41) 8.3% (1/12) P= NS 0.40 0.37 0.44 0.46 8.6% (5/58) 26.5% (9/34) 34.1% (14/41) 33.3% (4/12)P=0.04 P=0.003 0.23 0.37 0.71 0.44 P=0.02 P0.001 P=0.03 0 10 20 30 40 50 Ge L, et al. Heart,2006;92:371-376 Kissing Ballon No Kissing 0.6 0.4 0.2 Main Branch Side Branch 0 5 10 15 20 25 30 35 40 15.5% (9/58) 8.9% (8/90) 37.9% (22/58) 11.1% (10/90) 0.21 0.34 P = 0.10 P 0.05 P = 0.33 P 0.001 Restenosis (%) Late loss (mm)