钙化病变的治疗策略

Mintz et al. Patterns of Calcification in Coronary Artery Disease. Circulation April 1995, Volume 91, No 7,钙化病变,严重钙化病变的比例，在造影患者中为12%，而IVUS的发现率更高，达26%。,Severe Calcium in RCA,Shadow “Calcium Cast”,Mintz et al. Patterns of Calcification in Coronary Artery Disease. Circulation April 1995, Volume 91, No 7,钙化病变的危险因素,重度动脉粥样硬化高龄高钙血症高脂血症慢性肾功能不全,LAD: Severe Calcium and Balloon Waist,RCA: Severe Calcium and Balloon Waist,造影对钙化病变的判断,IVUS对钙化的判断,180 Arc of Superficial Calcium,270 Arc of Superficial Calcium,Superficial and Deep Mixed Calcium,Manual of Interventional Cardiology. Copyright Physicians Press 2001,IVUS判断钙化比造影更敏感,Manual of Interventional Cardiology. Copyright Physicians Press 2001Moussa, Moses, Columbo et al. Circulation 1997; 96:128-136,Stent Deployment in Heavily Calcified Vessel,Lumen,Unapposed Stent,钙化病变预后更差,支架更容易贴壁不良和不对称,MACE发生率增加,P = 0.0175,Consecutive 380 pts and 556 lesions treated with sirolimus-eluting stents were contact for 12 months,P = NS,P = NS,P 0.05,P 0.05,Kawaguchi R, et al. Cardiovasc Revasc Med. 2008;9(1):2-8.,Machecourt J, et al.JACC. 2007;50:5018,The EVASTENT registry: 1,731 patients undergoing revascularization exclusively with sirolimus stents,钙化病变是支架血栓的独立预测因素,并且 ,钙化使手术的成功率降低手术时间和X线曝光时间延长使手术复杂性增加 导丝和球囊更难以通过 支架和球囊更难以扩张 并发症发生率更高: 穿孔, 夹层, 无复流, 支架涂层损坏, 支架脱载,钙化导致的多聚物损伤,(AD) Scanning electron microscope images demonstratingdamage to the polymer of the Taxus stent (arrows).,Kitahara H, et al. Circ J 2008; 72: 1907 1908.,Proximal RCA Lesion Status Post TPA for Inferior MI Pre-Intervention,Post stent Deployment: single 2.75mm stent,介入医生的噩梦支架膨胀不全,Stents are contraindicated if a calcified lesion cannot be fully expanded with a high pressure balloon !,Stent underexpansion,钙化病变的处理要点,尽量避免处理钙化病变强支撑力GC导丝通过后，可先用小球囊预扩；宜选用低顺应性/半顺应性球囊，球囊无法扩张时禁忌植入支架中度钙化可考虑使用切割球囊，重度钙化需要旋磨,我们能采取的辅助措施,祛斑块 定向旋切 (DCA) 旋磨切割球囊激光技术,Calcification,Rotational atherectomy,Forward Pressure defines depth of diamonds “digging”Into vessel,Continuous movement keeps device from becoming Warm especially in angled/tortuous vessels,旋磨的原理,Orthogonal displacement of friction （直角旋转取代旋磨）Differential cutting (区别切割）,直角旋转取代摩擦,当滑动平面接触时摩擦产生。当滑动运动与接触平面垂直或呈直角时摩擦被减少。移动旋转速度越快，则摩擦产生的越少。例1：开酒瓶，旋转向上开法最省力。例2：取戒指，旋转移动最容易取血管迂曲时磨头阻力会增加，此时应与病变产生的阻力相鉴别，且应选择较小磨头。,Differential Cutting,区别切割：只对硬的血管有旋磨作用，对有弹性的血管如软斑块无旋磨作用。即旋磨头仅选择性清除无弹性、质硬的动脉粥样斑块组织，如钙化及纤维化斑块，而对有弹性的组织和正常冠状动脉无切割效应。,elastic,inelastic,旋磨产生的微粒,旋磨产生的斑块碎屑多数小于5m，比红细胞还小，这些小碎屑不会对冠状动脉血流产生明显影响，一般在通过毛细血管后在肝、脾和肺部被网状内皮系统清除。,Controlling particle size,PTCA后的损伤,旋磨后的损伤,PTCA 后的损伤,旋磨后的损伤,Compatibility of catheter and bur size,* an .004” clearance is recommended,Mostly can be performed by raidial acccess,RA的操作技巧: Selecting a bur,尽量采用小的磨头根据STRATAS研究的结果，磨头/血管比例0.6-0.7较好，一般从1.5mm或1.75mm开始，CTO病变可从1.25mm选起如果旋磨后仍无法通过支架，可逐渐增大磨头，每次增加0.25mm如果磨头阻力过大，减小磨头尺寸,啄木鸟技术,旋磨技巧,Time of runs 15“,Before ROTA,ROTA maneuver,1.5mm burr initiated,Back & Forth,After ROTABLATION,Balloon well expanded,1st stent deployed,Firebird 3.0*23mm,2nd stent deployed,Firebird 3.5*23mm,Final result,切割球囊,在普通球囊表面的纵轴上等角度地镶有34枚高度约为0.20.3mm的刀片球囊未完全打开之前，刀片先伸出，预先沿血管纵轴方向切开斑块纤维帽、弹力纤维和平滑肌这种“可控性”的扩张损伤可以减少内膜的不规则撕裂程度，最大程度地减少内皮细胞损伤以及管腔的弹性回缩,切割球囊的作用机制,Convention