（参考课件）介入中球囊及支架的应用.ppt

冠状动脉介入治疗的球囊和支架的应用,中国医学科学院阜外心血管病医院高展,1,冠状动脉介入治疗球囊的选择,2,球囊分类,整体交换球囊（OTW-overthewire)快速交换球囊(monorail),3,球囊的结构,球囊尖端球囊推送杆,4,球囊尖端,外径：直头圆弧锥形尖端与球囊的连接：胶水黏结热焊接激光焊接,5,球囊,球囊材料：尼龙、聚乙烯球囊顺应性折叠方式：三层折叠：利于回卷，后撤，低折叠减小通过半径标记方式：中央标记易于通过严重狭窄病变，双标记利于测量病变长度球囊肩部角度：球囊于尖部平滑过渡有利于通过病变球囊与中心杆的连接技术和材料：决定通过扭曲血管的能力,6,球囊性能,外径（crossingprofile)灵活性（flexibility)跟踪性（trackbility)推送性（pushbility)顺应性（compliance),7,球囊操作要领,8,预扩张,有利于支架的植入有利于病变的测量选择小于血管直径0.5-1mm的球囊进行预扩张，球囊长度应适当预扩张应尽量减少对正常血管的损伤为测量病变长度，使预扩张球囊在冠状动脉内进行造影时，注射造影剂的力度不宜过大，以免加重血管的撕裂对于狭窄程度重、较复杂的病变，预计支架通过较困难的病变应常规充分地预扩张，尤其对初学者,9,后扩张,防止支架贴壁不良，预防支架内血栓形成，降低再狭窄后扩张球囊可选择大一号的球囊或更高的压力后扩张时一定不能超出支架的边缘，尤其是的DES不可盲目追求所有病例的大球囊高压力的后扩张，以免增加无再流和冠状动脉破裂的风险,10,不同类型病变的球囊选择,CTO病变：常选择单标记、整体交换、小外径（1.5mm）球囊，如Maverick等长病变：原则上选用较长的球囊，以防两端撕裂并减少扩张次数。分叉病变：可选双导丝球囊、切割球囊。目的：减少斑块移位、降低分支闭塞的概率。,11,不同类型病变的球囊选择,小血管病变：宜选用外形小，推进性好的球囊。还可选用耐高压球囊。扭曲病变：应选择外形较小、推进性好的球囊。OTW球囊推进性较单轨球囊好，还有利于交换导丝钙化病变：应选择外形较小、推进性好的球囊。还可选用双导丝、耐高压乳突或切割球囊。,12,常用的球囊特点,13,MaverickPTCABalloonCatheters,ProprietarylaserbondedtechnologycreatesanextraordinaryTrakTipDesignandprecise,smoothbondsthroughouttheshaft.Pushcoildesignandimproveddistalflexibilityforenhancedtrackability.Our1.5and2.0mmSoftLEAPBalloonsofferenhancedcrossability.,14,ApexPTCADilatationCatheter,SlopeOuterShaftsmoothlytransitionsfromstifftoflexible,allinonepiece,formoreefficientpushtransmissionBi-SegmentInnerShaftoptimizesthebalancebetweenpushandtrackShorter,thinnermarkerbandsincreasedistalflexibilityRedesignedtipwithimprovedflexibilityandwiremovement;sameultra-low0.017profileOptiLEAPBalloonwithreducedwaistthicknessprovidesgreatsizingflexibilitywithlowerprofilesNano-compositematerialsaddsstructureandpushabilitytotheoutershaft,15,QuantumMaverickBalloon,Lowprofile,fulllength1.8For2.0FMonorailshaftLowprofile3.2Fproximalover-the-wireshaftBioslideCoatingonaPEBAXDistalShaftLaserbondingtechnologyQuantumLEAPBalloonMaterialTaperedTrakTipDesignwith.017lesionentryprofile*,16,QuantumMaverickBalloon,17,18,19,20,NCsprinter,外形细小的FasTrac头端技术-可在遇到较难通过的病变时提供极佳的通过能力；柔软耐用的FulcrumPlus球囊材料和MiniWrap折叠技术提供细小的外径和出色的再回抱能力；选择性的Dura-Trac涂层使球囊在到达和通过病变的过程中保持持久的润滑，在球囊扩张时保持稳定；渐细钢丝设计的推送杆增强了球囊的跟踪能力和通过远端病变能力；光滑细小的导丝交换口使3.5mm以下的任何两个球囊可在6F（0.070）的指引导管里对吻。,21,SunflexTipissuperblyengineeredtogiveaperfectbalancebetweenflexibilityandkinkresistance.Zerotransitionbetweenthetipandwireforsmoothestentryprofile.TaperedTip:ThetaperedsofttipcombinedwithadvancedlaserweldingtechnologyprovidesthemostcompetitivetipprofileSlidematrixdualcoatingisspeciallyformulatedwithtwouniqueproprietaryblends.HydrophilicandInviocoatingsareappliedtothedistalleadingtipsectionandtheballoon/shaftsection,respectivelytoprovideanoptimalbalancebetweenlubriciouscrossingandminimizingwatermelonseedingTightFoldprocessingresultsinaslenderprimaryprofileforenhancedcrossabilitythroughtightlesions.SapphireNC,OrbusNeich,22,TheIPTransitionZoneoftheAvitaPTCADilatationCatheterprovidesintensifiedpushability.Thenewtaperedtipdesignwithsoftmaterialexhibitsaflexibletipforsmoothlesionentryandminimalvesseltrauma.TheInviocoatingontheinnerlumeneliminatesfrictionbetweenthecatheterandguidewire.Invioisalsoappliedtotheouterdistalsegmentfromthetiptotheexitmarkerzoneforlubriciouscrossability.AvitaHP,OrbusNeich,23,Rugin,CrossTipTM确保Ryugin通过性可以达到的最高性能。CrossTipTM是由特殊混合的弹性塑料聚合物制作而成。0.017英寸(0.043毫米)的入口外径确保了Ryugin在完全闭塞的病变的复杂管腔里的通过性。CrossTipTM中等长度的柔韧前端能较易地通过移植支架处的病变并绷紧其钙化病变。亲水涂层M-Coating，塑料聚合物的复合层和新一代金属合金的Hypotube。使用Ryugin通过过度弯曲和大弯曲血管时，它能顺滑的到达目标病变部位，并且成功的处理其复杂闭塞病变。提供广泛有效的球囊直径选择范围从超细的1.25毫米直径到4.0毫米直径不等。薄型聚酰胺球囊确保了其卓越的通过性RyuginCrossTip是从尖端到薄型聚合物球囊的一段平滑过度部分，平滑柔韧的联合体能够通过各种复杂病变部位。泰尔茂新一代FC(FlexibleCorrugate)轴管成为连接高弹性的前端轴管和具备强硬金属的Hypotube轴管之间的桥梁。FC-shaft是指经过加工的柔软的胶质轴，该技术实现了通过一个平衡轴加强力量的传输性和弹性。,24,Voyager,SuperbCrossTaperedTipDesignNewtaperedtipwith.017”tipentryprofiledesignedtocrosstightlesionsImprovedtip-to-wireconformability1forconfidenttrackandcrossPolyurethanetipmaterialisflexibleyetdurablefortoughlesionsFlexibletungstenmarkertechnologyallowscathetertoconformtotortuousanatomyMoreOptionsLowProfileShaftDesignVersatiletreatmentina6FguideExcellenttrackandpushintortuousanatomywithnewhypotubedesignReinforcedmid-shaftdesignprovidesflexibilityandadditionalsupportFlexibilitywithVisibilityProprietaryTungstenMarkerNewmarkermaterialcomprisedoftungstenpolymerFlexiblemarkerdesignallowsthecathetertoconformmoreeasilytotortuousanatomyIncreasedmarkerflexibilityhelpstoreduceresistancewhencrossingtightlesionsPreciseDilatationProvenBalloonPerformanceShorttapersallowforprecisedilatationImprovedLOFOLDBalloonTechnologyprocessesallowsforexcellentrewrapandrecross1XCELONSBalloonMaterialachievessuperbflexibility,25,Powersail,PLATEAUBalloonMaterialProvidesnon-complianceathighpressurewithoutcompromisingperformanceFlexibilityandconformabilityforexcellentdeliverabilityLOFOLDBalloonTechnologyProvidesalowcrossingprofileforexceptionallesioncrossLOFOLDballoontechnologyforimprovedballoonrewrapSoftTipDesignTaperedtipdesigncreatesalowentryprofileandexcellenttip-to-wireconformabilityforeasylesionaccessSofttipprovidesflexibilityfornegotiatingtortuosityandcrossingstentstrutsDualSwagedMarkersProvidelowerprofilesthanconventionalmarkers,26,SafeCutusesdualwiremechanismtocreatefocusedforce.Ithasabuilt-in0.011integralwireexternaltotheballoontohelptracktortuousvesselswithgreatefficiency.Astandard0.014guidewirethatdeliversthecathetertothetargetlesionalsoparticipatesinthedilatationprocess.Theguidewireexitportislocatedattheproximalpartoftheballoon.Duringballoondilatation,thestandardguidewireandintegralwireapplycontrolledforcetofacilitateplaquefracturesatlowinflationpressures.Thesameapplicationalsohelpsminimizeballoonslippage.SafeCutsdistalleadingtipprofileis0.032taperedto0.028whichissmallerthanthoseofotherfocusedforceballoons.Balloonswithembeddedbladesforscoringthevesselhavehighcrossingprofilesduetothenatureoftheballoonmaterialsandblades.Theintegralwireandstandardguidewireapplyevenlydistributedforcetofacilitatecontrolledplaqueatlowpressures,reducingtraumatothevesselwall.Otherballoonsusingthesamefocusedforcetechnologyusebladeswhicharemuchmoretraumatictothevesselwall.,OrbusNeich,27,CuttingBalloon,TheFlexibilityYouWantNylonballoonmaterialdesignedtoprovideflexibility,superbcomplianceandimprovedpunctureresistanceOverallbetterdeliverabilitytotreatmorecomplexlesions.TheDeliverabilityYouNeed30%moreDeliverablethantheCuttingBalloonUltra2Device*50%improvementinre-crosscomparedtotheCuttingBalloonUltra2Device*ThePredictabilityYouRelyOnPrecisedilatationScoringtheplaquebyseveringtheelasticandfibroticcontinuityofthevesselwallDilatingthelesionatlowerpressureswithlessrecoilLumengainthroughplaquecompressioninsteadofvesselwallexpansion,28,冠状动脉介入治疗支架的选择,29,冠状动脉支架广泛应用的原因,植入支架后影像好，急性期结果好支架能够治疗急性或濒临闭塞，安全性明显提高支架降低再狭窄率，改善患者的长期预后植入支架容易操作支架的应用可以减少操作时间对于复杂病变，球囊扩张结果往往不理想，植入支架可以得到满意的结果,30,支架分类,根据设计不同，分为网状支架、管状支架、缠绕型支架、环状支架。根据材料不同，分为316L不锈钢支架、钴支架、铬支架、镍支架、钽支架。根据输送方式的不同，分为球囊膨胀性支架和自膨胀性支架。根据特殊用途而设计不同的支架，如适合分叉病变的支架和适合分支的支架以及针对冠状动脉瘤或穿孔的带膜支架根据是否带药，分为药物涂层支架和非药物支架,31,支架的性能特点,32,支架的开环和闭环设计,33,网眼大小,34,35,微米,支架丝厚度,36,金属动脉比值,37,支架可视性,38,39,40,41,裸金属支架选择原则,针对不同病变和支架的特性选择不同的支架支架的直径与参照血管的直径比为1.0-1.1长度将病变或夹层全部覆盖避免过长支架和一支血管植入多个支架，多个支架不可避免时应可能减少支架过多重叠,42,CordisConfidential-InternalUseOnly,药物,聚合物,支架,雷帕霉素和紫杉醇理想药物,聚合物最理想的释放系统,支架平台封闭单元式设计,药物洗脱支架,回缩和重塑,内膜增生,结果:安全性,疗效性,输送性,43,DES与BMS的比较,早期的临床试验随访4年结果表明，DES与裸金属支架（BMS）比，明显降低再次血运重建率，但死亡和心肌梗死（MI）两者没有差别。针对特定亚组患者的随机临床试验，如支架内再狭窄、慢性完全闭塞、糖尿病、小血管病变，也都证明了DES的优越性。但是由于这些标签外应用“off-label”的临床试验随访时间较短、样本量较小，对发生率较低的支架内血栓、死亡、MI这些终点事件无法鉴别，故对于DES应用于这些标签外指征尚无定论。,44,DES与BMS的比较,DES因为有涂层（polymer），所以较硬，顺应性和输送性较差，故对置入较困难的病变应选择BMS。DES较BMS昂贵，对于经济困难的患者应首选BMS。对于那些容易发生再狭窄的病变应选择DES。,45,建议的分类,介入治疗有用、有效证据偏向有用、有效有效的证据不充分介入治疗无效，甚至可能有害,46,Recommendation,原位病变（DeNovo）,ACC/AHA2005GuidelineforPCI,47,ACC/AHA2005GuidelineforPCI,-金属支架内再狭窄(vs.brachytherapy)-分叉病变(主支置入药物支架,分支PTCA或provisionalDES)-开口病变-慢性完全闭塞-多支血管病变(合并糖尿病)-静脉旁路血管病变,48,ACC/AHA2005GuidelineforPCI,49,ACC/AHA2007guidelineupdateforPCI,50,预扩张,如果预计支架植入困难，必须充分预扩张，以防止药物支架的涂层的损坏和支架的脱载如预计支架植入不会太困难，保证最小损伤措施包括：选择小一号的球囊（小0.5-1.0mm）短球囊（重点扩张最狭窄处并保证球囊长度永远短于拟用的DES支架长度）使用低压力预扩张（8atm）也可以选择使用稳定性好的短球囊（cuttingballoon或safecut）直接支架,51,药物支架选择和扩张,了解所有有关药物支架的技术规格说明支架直径的选择应基于对造影图象中血管的估测或定量的血管内超声图象的测量影像标准：支架的球囊:血管直径=1.1:1IVUS标准：应参考参照血管直径（如是渐细的血管，取近远段参照血管直径的平均值）,52,支架选择和展开,长度选择应强调支架“无病”区到“无病”区（或近段正常参照血管段到远段参照血管段），即支架应较病变长3-5mmIVUS和带有标记的引导钢丝对于选择药物支架的长度有帮助在裸金属支架时代，“越大越好”获取最大的术后最小管腔直径以抵消晚期管腔丢失（即显著的内膜增生）在药物支架时代，“长一些更好”保证病变的全部覆盖,53,药物支架选择和展开,输送药物支架过程中应避免用手接触支架过止血阀时，应充分打开，以防止对药物支架涂层的磨损如果药物支架难以跨过病变，避免过度用力推送，最好再次扩张后再次推送,54,后扩张,并非所有病例中应用的药物支架置入后都需要后扩张药物支架极低的晚期管腔丢失，没有必要像以往过度追求的造影效果；但是，应该选用另一个球囊扩张任何支架内不能被接受的狭窄或支架腰后扩张的球囊应该总是被定位于药物支架边缘以内（即总是用短于支架的后扩张球囊)后扩张球囊大小不应超过两个数量级,55,IVUS的重要性,支架置入前的应用（预扩张前或后）评价病变长度和血管渐变程度（包括参照血管内的病变）评价血管的大小评价病变与开口或分支血管的位置关系评价病变的形态学（可能影响预扩张或后扩张的策略）支架置入后的应用评价是否所有支架丝与血管壁完全贴附评价已被支架覆盖的区域（适当的支架大小是否贯穿整个病变）评价是否支架已覆盖全部病变对于多个支架-检查重叠区域以避免空隙,56,目前常用的药物支架特点,57,CYPHERSirolimus-elutingCoronaryStent,58,TAXUSExpressCoronaryStent,AProvenStentTheExpress2Stentplatformoffersexcellentdeliverabilityandconformability.AReliablePolymerTheTAXUSExpressStentusesTranslutePolymer,aproprietarypolymercarriertechnology,tocontroldrugrelease.AnEffectiveDrugTheuniquepropertiesofpaclitaxelcontributetotheefficacyoftheTAXUSExpressStent.Paclitaxelsmulti-functionaleffects,stabilizemicrotubulesandinhibitactivitiesthatcontributetorestenosis.3Paclitaxelishighlylipophilic,whichmaycontributetomoreuniformdrugdistribution.4,59,316L不锈钢材料支架梁厚度0.0038”尖端外廓0.017”通过外廓0.047”*,PicturestakenbyBostonScientific.,改善的通过性*,*Fora3.0mmstent,PicturestakenbyBostonScientific.,*BasedoninternalbenchtestsofthefeaturesoftheLibertStentcomparedtoExpressStentandmarketresearchresults.Dataonfile.,TAXUSLibert支架系统改善的输送性和顺应性,60,增强的TrakTip尖端,5折球囊技术,增强的TrakTip尖端外廓极小,提供了更好的病变通过和改善的跟踪性.*,该设计减少了支架的旋转,增强了支架的固位.,改善的输送性和顺应性*,PicturetakenbyBostonScientific.,*BasedoninternalbenchtestsofthefeaturesoftheLibertStentcomparedtoExpressStentandmarketresearchresults.Dataonfile.,TAXUSLibert支架系统改善的输送性和顺应性,61,支架平台比较血管覆盖,TAXUSLibert支架,TAXUSLibert支架的小的单元面积设计可以保持出色的血管覆盖和支持,同时减少组织下垂的危险*.,Cypher支架,TAXUSExpress2支架,*Cellareavariabilitybaseduponstentdiameter.ImagestakentakenbyBostonScientificof3.0mmdiameterstents.CypherisatrademarkofCordisCorp.DriverisatrademarkofMedtronic/AVE.,CypherSelect支架,Driver支架,62,命名压力,额定爆破压力,命名压力,TAXUSLibert支架系统支架顺应性图表,ATM直径(mm)2.252.502.753.03.582.762.973.4392.192.442.813.023.49102.242.492.873.083.56112.292.552.933.143.63122.322.592.983.193.68132.362.643.023.233.73142.392.673.063.273.78152.422.703.093.313.81162.442.743.123.343.85172.742.763.143.373.882.492.793.173.393.92,NominalpressureforTAXUSExpress2:9ATM,Caution:Thisisaninvestigationaldeviceandisnot