病变的技巧冠心病最新进展ppt课件

慢性完全闭塞病变介入技慢性完全闭塞病变介入技 巧和器械选择巧和器械选择 北京安贞医院 吕树铮 教授 慢性完全闭塞病变介入技巧和器械选择慢性完全闭塞病变介入技巧和器械选择 l慢性完全闭塞病变的相关概念 l慢性完全闭塞病变的病理结构和特点 lCTO介入的导丝选择 lCTO病变的支架选择 CTOCTO的定义的定义 l闭塞时间大于3个月的病变 CTOCTO病变形成时间的判断病变形成时间的判断 lAMI的时间 l症状加重的时间 l侧枝循环形成的多少及侧枝的直径 CTOCTO病变长度的判断病变长度的判断 l顺行显影 l逆行显影 l双向造影 顺行显影顺行显影 逆行显影逆行显影 CTOCTO病变的病理结构病变的病理结构 1. 坏死脂核、胆固醇结晶及钙化 CTOCTO病变的病理结构病变的病理结构 2. 细胞外基质：胶原、钙化 CTOCTO病变的病理结构病变的病理结构 3. 微血管 CTOCTO病变的类型病变的类型 l重度狭窄慢性闭塞 l轻中度狭窄慢性闭塞 重度狭窄慢性闭塞重度狭窄慢性闭塞 主要由纤维化和钙化的粥样硬 化斑块组成 短闭塞段：纤维帽位于闭塞段 的两侧边缘，中间为血管壁重 塑形成的组织，闭塞时间一般 为3个月以上，重塑的组织中含 有大量的纤维组织 长闭塞段：常常有血栓的成分 ，闭塞段往往是纤维组织与血 栓相间分布。这种病变导丝很 难通过，成功率只有5070% 轻中度狭窄慢性闭塞轻中度狭窄慢性闭塞 脂核 纤维组织 陈旧血栓 原有轻中度狭窄病变， 班块破裂，未及时治疗 ，导致血管慢性闭塞， 新的闭塞处远离原有狭 窄斑块，导丝注意寻找 闭塞斑块 CTOCTO病变的病理特点病变的病理特点 l粥样斑块+钙化慢性发展融合而成 CTOCTO病变的病理特点病变的病理特点 l斑块破溃形成血栓机化而成 CTO介入的导丝选择 导丝的结构导丝的结构 导引导丝的性能导引导丝的性能 调节力：导丝尖端和中心钢丝结构 柔软性：导丝的直径、尖端结构和连接 段变系程度 推送力：中心钢丝的硬度和中间变细方 式 支持力：中心钢丝的直径和材料 处理处理CTOCTO病变时常用的导丝病变时常用的导丝 l超滑导丝：如PT Graphic Intermediate、 PT2、 Shinobi 、 Cross NT、Whisper等 lCoil型导丝：ACS Intermediate Standard、 Cross IT100-400、Miracle3-12及Conquest (Pro)9-12等 处理处理CTOCTO病变时常用导丝病变时常用导丝 l超滑导丝 SCIMED PT2SCIMED PT2 The combination of a polymer cover and hydrophilic coating provides outstanding lubricity. SCIMED PT Graphic IntermediateSCIMED PT Graphic Intermediate Uni-body core with long, smooth taper from support region to tip Hydrophilic-coated, polymer sleeve and tip Intermediate wire with slightly stiffer tip Crossing performance of polymer tip with visibility of spring tip Terumo CrossNTTerumo CrossNT WHISPER Redefines Polymer Wire Performance ResponsEase grind technology DURASTEEL core material Polymer Coated/ Hydrocoat Distal segment Soft tip designed for frontline use HI-TORQUE PILOT Design HI-TORQUE PILOTHI-TORQUE PILOT Family Family Product DescriptionProduct Description Design Highlights: Polymer-tip, hydrophilic Core-to-tip with moderate support Graduated tip stiffness in the family Modified RESPONSEASE parabolic grind DURASTEEL core material Single lesion measurement marker The HI-TORQUE PILOT family of guide wires offers a choice of wires that vary in tip stiffness to address a wide variety of lesion morphology. Tip coils beneath the polymer help facilitate tip shaping. Modified RESPONSEASE Parabolic Grind This modified RESPONSEASE design provides additional support, excellent torque transmission and in-lesion tip control. The HI-TORQUE PILOT guide wires maintained their tip shape better than competitive wires after passing through a tortuous path model. The DURASTEEL core material of the HI-TORQUE PILOT family is stronger than conventional stainless steel for improved core strength and tip shape retention. DURASTEEL withstands more pulling force than regular 304v stainless steel. .007” Corewire Support PTFE 喷涂 近端 黑色的PTFE 袖套延伸至远端头部 平的显影线圈 Shinobi 43(11):1954-8. -56例CYPHER治疗 Ge L., et al.,Eur Heart J 2005:26(11):1056-62 -122例CYPHER治疗 Nakamura S., et al., Am J Cardiol 2005;95:161-6 - 60例CYPHER治疗 The SICTO Study CYPHER TM Sirolimus-eluting stent in Chronic Total Occlusion The PRISON II Study Primary Stenting of Occluded Native Coronary Arteries SICTO SICTO STUDY DESIGN A multicenter, prospective, non-randomized study to assess the feasibility and restenosis/reocclusion rates of coronary stenting with the CypherTM Sirolimus-eluting stent in patients with chronic total occlusion - 25 patients were treated with the CypherTM Sirolimus- eluting stent after successful balloon angioplasty and IVUS examination. - Clinical follow-up at 30 days, 6, 12, 18 and 24 months - repeat angiography and IVUS at 6 months follow-up. SICTOSICTO Conclusion Conclusion In this feasibility study the CYPHERTM Sirolimus- eluting stent was very effective in the treatment of CTO, with very low rates of TLR (0%), MACE (0%) and TVR (8%) compared to historical data with bare stents (30-50%). The CYPHERTM Sirolimus-eluting stent significantly inhibits intimal hyperplasia in CTO. These preliminary data will come in addition of larger database with CTO subpopulation (e.g. e- Cypher) PRISON IIPRISON II Study Study To compare the immediate and long-term angiographic and clinical results of BMS (Bx Velocity) implantation with Sirolimus-eluting Stent (CYPHER) implantation for the treatment of CTO 6-month Clinical Follow-up6-month Clinical Follow-up Clinical Event (%) 20 4 P0.001 24 8 22 8 19 4 32 0 P=0.003P=0.009P=0.001P=NSP=NS 0 6-month Angiographic Follow-up 6-month Angiographic Follow-up In-StentIn-Stent BMS (n=94)SES (n=94)p value Ref. diameter (mm)3.01 0.853.44 0.540.0001 MLD (mm)1.47 0.832.48 0.800.0001 % diam. stenosis48.75 26.5222.01 20.980.0001 Late Loss (mm)1.09 0.910.05 0.810.0001 Net gain (mm)1.30 0.882.33 0.850.0001 Loss index0.45 0.37-0.02 0.410.0001 P0.0001 P0.0001P0.0001P0.0001 41 36 11 7 % 73%81% Angiographic Binary Restenosis Relative Risk Reduction ConclusionsConclusions As compared with bare metal stents, the CYPHER sirolimus-eluting stent implantation in CTO is su