高危复杂的冠状动脉介入治疗jian

1,Percutaneous Coronary Intervention in High-risk and Complex Lesions,周玉杰 贾德安首都医科大学附属北京安贞医院,2,泡沫细胞,脂纹,轻度病变,动脉瘤,纤维斑块,复合病变/ 破裂,动脉粥样硬化的进程,Adapted from Stary HC et al. Circulation 1995;92:1355-1374.,动脉粥样硬化的发展进程,3,DES：Restenosis:5-10%,介入治疗的三大里程碑,Bare Stent：Restenosis:20-30%,PTCARestenosis:30-50%,since 1978,since 1986,since 2003,4,高危-复杂冠心病的特点,高龄合并复杂疾病 急性心肌梗死、心功能不全、肾功能不全、肿瘤、脑卒中冠脉复杂病变 完全闭塞病变、弥漫性病变、多支病变、左主干病变、严重钙化、血管重 度迂曲、再狭窄病变,5,高危、复杂冠心病治疗策略的选择应权衡风险和收益,(1)患者的全身情况能否耐受操作(2)心肌缺血的严重程度(3)手术操作成功的可能性(4)处理并发症的能力(5)远期效果(6)费用,6,老年患者,对老年UA/NSTEMI患者，早期血管重建治疗的风险较年轻患者增加，但接受PCI治疗后总体获益更大对老年UA/NSTEMI患者，应考虑到患者和家属的意愿，生活质量、社会文化因素和治疗的效价比,ACC/AHA 2007 Guidelines for NSTE-ACS. Circulation , 2007; 116;803-877.,7,糖尿病,UA/NSTEMI 患者急性期的药物治疗和决策（运动试验、造影和血管重建）在糖尿病和非糖尿病患者中相似对所有患有糖尿病的UA/NSTEMI患者，均应静脉使用 GP IIb/IIIa受体拮抗剂糖尿病患者接受PCI治疗获益更大,ACC/AHA 2007 Guidelines for NSTE-ACS. Circulation , 2007; 116;803-877.,8,TACTICS-TIMI-18 trial 6-month events,Cannon CP. N Engl J Med 2001;344:1879.87.,9,Glucose level should be a part of the initial laboratory in all pts with ACS Consider intensive glucose control in pt with hyperglycermia (180mg/dl)Insulin (iv) most effective method,AHA Scientific Statement. Circulation 2008;117;1610-1619,糖尿病,2008 NEW,10,糖尿病,对表现为UA/NSTEMI的糖尿病多支病变患者，使用乳内动脉的CABG优于PCI对患有糖尿病单支病变和可诱导性缺血的UA/NSTEMI 患者，推荐行PCI治疗,ACC/AHA 2007 Guidelines for NSTE-ACS. Circulation , 2007; 116;803-877.,11,搭桥术后,对于伴有多处SVG狭窄的UA/NSTEMI患者，可再次CABG，特别是对LAD桥血管严重狭窄的患者。静脉桥血管局限性狭窄的患者可行PCI治疗对CABG术后的UA/NSTEMI 患者，可行影像学负荷试验,ACC/AHA 2007 Guidelines for NSTE-ACS. Circulation , 2007; 116;803-877.,12,EF 50危险性增高EF 30危险性极高球囊充盈时间延长、造影剂过多可导致心功能迅速和进行性恶化必要时IABP支持经桡动脉PCI更加可行,高危、复杂冠心病 PCI 治疗合并心功能不全,ACC/AHA 2007 Guidelines for NSTE-ACS. Circulation , 2007; 116;803-877.,13,慢性肾病,对UA/NSTEMI患者，应估算肌酐清除率，并适当调整经肾脏代谢药物的剂量对慢性肾脏疾病患者，推荐使用等渗造影剂,New Section,ACC/AHA 2007 Guidelines for NSTE-ACS. Circulation , 2007; 116;803-877.,14,从SCr计算eGFR的公式 :,高危、复杂冠心病 PCI 治疗合并肾功能不全,简化MDRD公式的原始形式：eGFR(ml/min/1.73m2)=186SCr(mg/dl)-1.154年龄-0.203(0.742女性) (1.21黑人)适合中国人的改良形式：eGFR(ml/min/1.73m2)=175SCr(mg/dl)-1.154年龄-0.203(0.79女性),Ma YC, Li Z, Chen JH, et al. Modified Glomeruar Filtration Rate Estimating Equation for Chinese Patients with Chronic Kidney Disease J Am Soc Nephrol.2006;17:2937-2944.,15,国人MDRD公式测eGFR,年 龄,肌酐值,MDRD,mL/min/1.73m2,MS PowerPoint slide 2003 Stephen Z. Fadem, M.D. and Brian Rosenthal.All rights reserved,Levey AS et al. Ann Intern Med. 1999;16:461-470, J Am Soc Nephrol. 2000; Sep (11): A0828. NKF K/DOQI 指南 慢性肾脏疾病,16,“慢性肾病” (CKD) 肾功能肾小球滤过率(mL/min/1.73m2) 肌酐清除率 (mL/min),National Kidney Foundation. Am J Kidney Dis. 2002;2(Suppl 1):S46S75.,130 120 110 100 90 80 70 60 50 40 30 20 15 10 0,肾脏病预后质量创议(Kidney Disease Outcome Quality Initiative )的肾功能分类,第I阶段,轻度肾功能减退 ,中度肾功能减退,第II阶段,第III阶段,第IV阶段,第V阶段,重度肾功能减退,肾衰ESRD,CKD 危险因素/肾脏损害但保留GFR功能,C.I.N.,17,高危、复杂冠心病 PCI 治疗合并消化道出血疾病,抗血小板药物减量 （阿司匹林）肝素减少2040抗酸制剂：洛赛克 泰胃美胃粘膜保护剂,ACC/AHA 2007 Guidelines for NSTE-ACS. Circulation , 2007; 116;803-877.,18,高危、复杂冠心病 PCI 治疗合并肿瘤,肿瘤病人发生ACS时，远期临床效果不佳，可能与肿瘤患者高凝状态发生血栓栓塞并发症有关调整应用抗血小板等影响凝血机制的药物可以改善病人的预后,ACC/AHA 2007 Guidelines for NSTE-ACS. Circulation , 2007; 116;803-877.,19,高危、复杂冠心病 PCI 治疗完全 VS. 部分血运重建,多支病变的PCI治疗，完全血运重建成功率较低，MACE无明显差异，但部分血运重建患者再次血管重建治疗的比例较高 Am Heart J. 2004 Sep;148(3):467-74完全血运重建可以改善糖尿病多支病变患者的长期预后 J Invasive Cardiol. 2004 Mar;16(3):102-6.,20,高危、复杂冠心病 PCI 治疗完全 VS. 部分血运重建,J Invasive Cardiol. 2004 Mar;16(3):102-6,21,高危、复杂冠心病CABG VS PCI,CABG 手术创伤较大, 恢复时间长重复PCI较重复CABG简便易行，在紧急情况下能更迅速达到血管重建 对于糖尿病、多支血管弥漫病变、左心室功能减退、左主干远端以及伴有前降支开口病变的多支病变和通过PCI不能达到完全血管重建的患者，选择CABG更为有益 ？病变越广泛越弥漫，越应选择CABG？,22,A.R.T.S.II为复杂冠脉病变选择PCI策略提供了依据,Patrick W Serrays. 2005 ACC.,23,Serruys教授： SES可能替代CABG成为冠脉多支血管病变患者的首选!,24,PCI联合外科hybrid 方法,25,DES降低MACE，IMA长期开通率，联合药物治疗保证杂交手术长期效果联合药物洗脱支架和最新外科手术方法（小切口、非体外循环、机器人协助、内乳桥血管）保证患者最大获益、小创伤、低费用、更有效,杂交手术优势,26,HYBRID手术室,27,Byrne et al, JACC 2005;45:14,3.8%,22%,高危患者中Hybrid方法改善临床预后,28,高危、复杂冠心病 PCI 治疗经桡动脉PCI,优点:术后止血容易，穿刺部位并发症少术后无需平卧，适于严重心衰患者住院时间短,费用相对较少,29,高危、复杂冠心病 PCI 治疗经桡动脉PCI,经验轻柔简洁精确应用超滑导丝和4F造影导管，可基本避免血管痉挛经桡动脉通路时，Judkins左冠导管型号应比经股动脉通路小一号病变位于近端或右冠走行向上、迂曲时，Amplatz，XBRCA导管更合适病变在前降支，XB,EBU导管同轴性较好；若病变在回旋支，Amplatz左冠导管同轴性较好,30,高危、复杂冠心病 PCI 治疗抗凝治疗,肝素/低分子量肝素在非ST抬高ACS中的疗效已经得到证实低分子量肝素在ST抬高的急性心肌梗死中已经显示了明确的效益新的抗因子Xa抑制剂可能具有相等的效益但较少的不良作用,31,高危、复杂冠心病 PCI 治疗双联抗血小板治疗,冠脉支架术后，包括阿司匹林和氯吡格雷的双联抗血小板治疗可明显减少心脏事件的发生药物洗脱支架植入后应坚持12个月双联抗血小板治疗，高危患者应进一步延长过早停用双联抗血小板治疗会大大增加支架血栓、心肌梗死和死亡发生的风险,Science advisory from AHA/ACC/SCAI/ACS/ADA. Circulation. 2007;115(6):813-8.,32,北京安贞医院高危复杂病变介入治疗协议,患者属高危复杂病变告知患者及家属冠脉搭桥和介入治疗的利弊如患者及家属拒绝冠脉搭桥，同意介入治疗进行完全或部分血运重建，并承担其风险,33,CASE 1,78 yso maleunstable angina, aggravating chest painECG changes of T waves in I, avL, V3-6Hypertension, Hyperlipidimia, chronic renal failure, heart dysfunctionNon-smoker, no diabetes mellitus,34,Coronary Angiography,LAD: CTOLCX: ostial,35,Case analysis,AdvantageNo diabetesRelative short occlusion segment Occlusion segment showed by collateralPossible high success rate of patency of CTO,DisadvantageMale, elderly, CRF (Scr=2.8mg/dl,)EF=50%Unknown occlusion timeMulti-vessel lesions including LM bifurcationTortuous vessel for trans-radial approachTreating strategy CABG or PCI ?,36,Case strategy,Select PCI ! If fail to open occlusion, turn to CABG.2 steps! Avoiding too much consumption of CM due to CRFAvoiding impairment of LM, the ostial of LCXIABP preparedGuiding catheter, good active and passive backup, good coaxialGuide wire for CTO, e.g., cross it 100-400,37,Problems may meet,Difficult to certify the true lumenPerforationDissectionThe impairment of LM and LCXToo much contrast media, maybe CIN caused. Visipaque is the suitable choice, which could significantly reduced CIN by 88% than LOCMToo much time, patient cannot toleratedThe feeling of patient, e.g., fear, discomfort,Aspelin P ,etc N Engl J Med. 2003 Feb 6;348(6):491-9.,38,Guide wire crossing the proximal occlusion segment of LAD,BL3.5 Heart trail (Terumo),cross IT 100200,39,Right path of guide wire certified by contralateral CA,DC 4FJR4(cordis),Side branch,Main branch,Cross it 200,40,Get better support , better coaxial, application of micro-catheter in CTO,Progreat (terumo),true lumen,41,GW BMW,Exchange a soft wire through micro-catheter,Avoiding complication must abide by regulation! Safety of Pts is the first!,42,Dilation of LAD,GW BMW,GW runthrough,Balloon dilated in LAD,Balloon:1.5-15mm change 2.0-20mm,43,Undesired problem, but predicted before operation!,dissection,44,What can we do?,Must keep the wire oppositionObserve?Low pressure dilation?Stenting? STENTING immediately!,45,Stent implanted at the distal of dissection first,Cypher select 2.5*33mm,46,Caution: position of the proximal end,Cypher 3.0*33mm,Cypher 2.5*33mm,overlapping,47,Not ideal result after dialation D2,48,Kissing balloon is necessary,Ryujin2.0*15mm,Ryujin2.5*15mm,49,Final result after 1st procedure,50,2nd procedure,To treat the lesion of LM-LCXWhich techniques is suitable? T-technique maybeHow to avoid the ostial lesion of LADKissing balloon necessary?The selection of GC,51,Tortuous brachiocephalic trunk,NO collateral blood from RCA to LAD,Coronary Angiography,52,Wire placed in LAD and LCX,GW BMW,GW BMW,GC 7F SL4.0,53,Balloon dilated in LCX,54,Stenting in LCX,Cypher select 3.0*33mm LM-LCX,55,After stenting LM-LCX,56,Kissing balloon technique: LM-LCXLAD,BC HYPRO GRIP3.0*15mm,BC SPRINTER 2.5*20mm,57,Final result,58,Summary,Trans-radial approach PCI for complex lesions is safe and feasible (PCI with 6&7F GC follow-up for 9mon.)Combined techniques flexibleBe careful of the consumption of CM, esp, in elder, IOCM (iso-osmia contrast media) is the better choice,59,Guidelines for the Diagnosis and Treatment of NSTE-ACS,References：190,1st edition 2000,2nd edition2002,References：218,3rd edition2007,References：514,Newest,60,NSTE-ACS介入治疗适应症,紧急PCI(120分钟内)：1.患者出现持续性或反复胸痛，伴有或不伴有ST改变（2mm）或深的倒置T波，抗缺血治疗效果不好2.出现心衰临床症状或血流动力学不稳定3.致命性心律失常（VF、VT）,2007-ESC,ESC guideline for NSTE-ACS. Eur Heart J. 2007; 28:1598-1660,61,早期PCI (72小时),TnT或TnI升高 动态ST或T改变（有症状或无症状）糖尿病 肾功能异常（GFR60ml/min/1.73m2）左心室功能降低（LVEF40%）梗死后心绞痛有MI病史6个月内行PCI ,有CABG史中高GRACE危险记分,2007-ESC,ESC guideline for NSTE-ACS. Eur Heart J. 2007; 28:1598-1660,62,低危：不做或择期,无再发胸痛无心衰的体征无新的ECG改变（就诊6-12小时）TnT 或I正常（就诊6-12小时）,2007-ESC,ESC guideline for NSTE-ACS. Eur Heart J. 2007; 28:1598-1660,63,Guidelines for the Diagnosis and Treatment of NSTE-ACS,1st edition 2000,References：515,2nd edition2002,References：552,3rd edition2007,References：957,Newest,64,ACC/AHA 2007 Guidelines for NSTE-ACS,Anderson JL, et al. J Am Coll Cardiol. 2007;50:e1-e157,高危患者介入治疗低危患者保守治疗（TIMI/GRACE）,Key Points,65,Early Risk Stratification TIMI Score,Antman EM, et al. JAMA 2000;284:83542.,年龄65危险因素3个冠状动脉狭窄50%心电图变化24小时心绞痛发作2次既往1周使用阿司匹林心肌标志物升高,7项因素，每项1分,66,Early Risk Stratification GRACE Score,Eagle KA, et al. JAMA 2004;291:272733.,67,NSTE-ACS诊断与治疗指南,Newest,68,急性胸痛的诊断及处理流程（卫生部冠心病诊疗标准）,2008Unreleased,69,NSTE-ACS的早期危险分层（卫生部冠心病诊疗标准）,2008Unreleased,70,男性 65岁不稳定心绞痛病史2个月06年12月17日“急性前壁心肌梗死，陈旧性下壁心肌梗死”在当地医院治疗外院2次PCI；安贞医院第三次介入治疗,CASE 2 策略决定命运,71,1st Procedur,ostial RCA CTO,Jan. 2, 2007 -CAG,72,Jan. 2, 2007 -CAG,mid LCX-99%,mid LAD-99%,73,Balloon-LAD,74,STENT-LAD,75,LCX-STENT,Is it necessary to treat LCX simultaneously?,76,ASA 0.1 QdClopidogrel 75mg QdDischarged 5 days after PCI severe chest pain at the sixth day after PCIWhat happened?,77,2nd Procedure,Jan. 8, 2007 -CAG,78,Balloon- LCX,HR,BP,ACUTE HEART FAILURE,79,WHATS WRONG?,Technique?Strategy?,80,We call them to injected r-TPA 10-40-50mg, Jun. 17, 2007 transfer to our dept. UCG: apex aneurysmakinasis at apex, anterior and basal wall LV 63/55EF 35TC: 5.14mmol/lLDL-C: 4.15mmol/l,81,What should we do?,DO PCI, AS SOON AS POSIBLE? WAITING? DRUG THERAPY? AGGRESSIVE DRUG THERAPY + PCI?,82,ASA 0.3 QdClopidogrel 75mg QdLipitor 60mg QnLWMH ih Q12hSelected PCI after 2 weeks,Medical therapy,83,Jan. 30, 2007,3RD Procedure,LAD LCX病变不战而胜！,84,6FJR3.5Launcher GCHT Pilot 50 HT Pilot 150,Ryujin 1.25x15mmSeQuet CTO 2.0x15mm,85,ENDEAVOR 2.5x24mm,86,启示,不要在病人身上做得过多越复杂的病变可能越有简单的方法保守治疗、强化药物治疗有时会有意想不到的效果,87