复杂冠脉分叉病变的PCI治疗策略.ppt

PCIStrategiesforComplexCoronaryBifurcationlesions,首都医科大学附属北京安贞医院周玉杰聂斌BeijingAnzhenHospital,Oneortwostents?,NordicBifurcationStudy(n=413),413ptswithbifurcationlesion,Stentingofthemainvesselandsidebranch(MV+SB),Stentingofthemainvesselandoptionalstentingofthesidebranch(MV),n=206,n=207,Randomized,PrimaryEndpoint:Majoradversecardiacevent(MACE)at6months,PrimaryEndpointofMACEat6months(%)p=NS,PresentedatACC2019,Therewasnodifferenceinmajoradversecardiaceventsat6months(17.7%vs12.7%;p=NS),NordicBifurcationStudy(n=413),ProcedurerelatedMIwasdefinedasafive-foldelevationofbiochemicalmarkersProcedurerelatedMIoccurredmorethanthreetimesasoftenintheMV+SBgroup(13%vs4%;p=0.008),ProcedureRelatedMyocardialInfarction(%)p=0.008,PresentedatACC2019,NordicBifurcationStudy(n=413),OneStentStrategy,ProvisionalTStenting,ProvisionalTStent,Provision-Tstenttechnique,53pts,SB2mmMACE9.4%at14+/-3monthsTLR3.8%,MVrestensosis3.2%,SB12.9%at6months,VignaC,etal.JInvasiveCardiol.2019Mar;19(3):92-7.,TheSBhasanarrowingatitsostium,TheMBhasseverestenosiswithalargeplaqueburdenandtheSBoriginateswithanangleof45,TheostiumoftheSBdeterioratesafterpre-dilatationoftheMB,Awireisneededinthefollowingcircumstances:,ProvisionalTStent,FKBisVeryImportantforProvisionalTStent,ProvisionalTStent,TwoStentsTechniques,TstentCulotteSKSVstentProvisionalTModifiedTstentYstent,BMSEra,DESEra,Crush,ReverseCrush,BalloonCrush,DKCrush,Mini-Crush,InvertedCrush,TstentTechnique,CulotteTechnique,ClinicalOutcomes,InBMSera,theincidenceofTLRwas24%at6months(Chevalier.AmJCardiol2019;82:943)InDESera,theincidenceofMACEwas5.3%andTLRwas15.4%(Hoye,etal.IntJCardiovascinterven2019;7:36),CulottevsTstentinDESera,80patientswithbifurcationlesions,Culottetechnique45cases,Tstent35cases,Theproceduralsuccessrate100%TLR:8.9%P=0.014;9monthsMACE13.3%P=0.051,KaplanS,etal.AmHeartJ.2019Aug;154(2):336-43,Theproceduralsuccessrate100%TLR:27.3%9monthsMACE27.3%,SKSTechnique,ClinicalOutcome,200patientswithbifurcationlesions,SKStechnique,Cypherstents,Theclinicalsuccessrateis97%TheincidenceofTLR:4%9+/-2months,SharmaSK.CatheterizationandCardiovascularInterventions2019;65:10,ClinicalOutcome,36patientswithbifurcationlesions,SKStechnique,SESstents26.7+/-8.6month,Theproceduresuccessrateis100%NoMACE,MBrestenosis13%,SB10%TheincidenceofTLR:14%,KimYH,etal.CatheterCardiovascInterv.2019Nov15;70(6):840-6,YStentTechnique,CrushTechnique,ClinicalOutcomes,ThesurvivalratefreeofTLRwas90.3%,incidenceofrestenosisatMBwas9.1%,restenosisatSBwas25.3%(HoyeA.JAmCollCardiol2019;47:1949-1958)IncidenceofTLRat6monthfollow-upis11.3%(MoussaIAmJCardiol2019；97：13171321),Colomboetal.PCR2019,FinalKissingisveryimportant!,Step1:Wirebothbranchesandpredilateboth,Step2:Bothstentsinplace.Side-branchstentpositionedmoreproximal,InvertedCrush,Wirebothbranchesandpredilate,Deploystentinmainbranch,Reversecrushingtechnique,Wiresidebranchanddilate,PositionstentinsidebranchprotrudinginMB(slight),leaveaballooninMB,Deploystentinthesidebranchandremovewireandballoon,CrushtheprotrudingpartofSBontopofthestentinMB,BalloonCrush,DKCrush(SleeveTechnique),mini-crush,45pts,52lesionsProceduralsuccess100%Noin-hospitalMACETLR12.2%,MVrestensosis12.2%,SB2%at8months,GalassiAR,etal.CatheterCardiovascInterv.20191;69(7):976-83,TAPtechnique,Wirebothbranchesandpredilate,Deploystentinmainbranch,Wiresidebranchanddilate,Kissingballoon,SBstentpositioning,SBstentisdeployedwiththeuninflatedballoonintotheMV,TheballoonoftheSBstentisslightlyretrievedandalignedtotheMVballoon,Finalkissingballoon,InvitroTAPstenting,PerfectcoverageofthebifurcationwithminimalstentsstrutsoverlapattheproximalpartofSBostium,0.070”0.071,0.078”,6F,7F,5.3F,5.4F5.9F,Tipsandtricks,SizeofGuidingCatheter,MVballoonshaftprofile+SBstentshaftprofile,8F,6.0F,0.088”,6F,7F,8F,GC,5.4F0.0705.3F,6F导管完成对吻扩张,6F导引导管的内径：0.0700.071),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=5.5F6F导管内径：0.070inch5.4F,选用导引导管：6FJL3.5,CaseofTAPstenting,CoronaryAngiography,6FEBU3.5,BMW,BMW,3.024mmCypher,DeploymentMVstentwithjailedguidewireintotheSB,KissingballoonafterrewiringofSB,SBstentpositioning,SBstent,MVballoon,ThepositionoftheSBstentisadjustedtofullycovertheproximalpartoftheSBostium(redarrow)whileanuninflatedballoonkeptintotheMV,SBisdeployedwiththeuninflatedballoonintoMV,SBstentdeployment,Finalkissingballoon,TheballoonoftheSBstentisslightlyretrievedandalignedtotheMVballoon,FinalkissingballoonSBstentsballoonMVballoon,FinalResult,ClinicalstudyofTAP,BurzottaF,etal.CatheterizationandCardiovascularInterventions2019,70:7582,Angiographiccharacteristics,Procedurecharacteristics,Clinicaloutcome(9month),StrategiesforLMCAlesions,Stentimplantationinthesidebranch?,No,Yes,6FGuidingCatheter,TreatmentStrategy,Balloon/DK/ReversecrushProvisionalTstent/Culotte,Standardcrush/SKSModifiedTstent,6FGuidingCatheter,7FGuidingCatheter,SelectthesizeofGC,116ptswithLMCAbifurcationlesions,Cross-over(n=67),Complexstrategy(n=49),SKS(n=24),Crush(n=25),KimYH,etal