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.,The SB has a narrowing at its ostium,The MB has severe stenosis with a large plaque burden and the SB originates with an angle of 45,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,T stent Culotte SKS V stent Provisional T Modified T stent Y stent,BMS Era,DES Era,Crush,Reverse Crush,Balloon Crush,DK Crush,Mini-Crush,Inverted Crush,T stent Technique,Culotte Technique,Clinical Outcomes,In BMS era, the incidence of TLR was 24% at 6 months (Chevalier. Am J Cardiol 1998;82:943) 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,The 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 ) Incidence of TLR at 6 month follow-up is 11.3% (Moussa I Am J Cardiol 2006；97：13171321),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 F,GC,5.4F0.0705.3F,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 inch5.4F,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,Procedure characteristics,Clinical outcome (9 month),Strategies for LMCA lesions,Stent implantation in the side branch?,No,Yes,6F Guiding Catheter,Treatment Strategy,Balloon/DK/Reverse crush Provisional T stent/Culotte,Standard crush/SKS Modified T stent,6F Guiding Catheter,7F Guiding Catheter,Select the size of GC,116 pts with LMCA bifurcation lesions,Cross-over (n=67),Complex strategy (n=49),SKS (n=24),Crush (n=25),Kim YH, et a