介入中球囊及支架的应用

1、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,冠状动脉介入治疗球囊的选择,球囊分类,整体交换球囊（OTW- over the wire) 快速交换球囊 (monorail),球囊的结构,球囊尖端 球囊 推送杆,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,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,球囊性能,外径（crossi

2、ng profile) 灵活性（flexibility) 跟踪性（trackbility) 推送性（pushbility) 顺应性（compliance),球囊操作要领,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,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

3、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,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（1.5 mm）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。,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

4、选用双导丝、耐高压乳突或切割球囊。,常用的球囊特点,Maverick PTCA Balloon Catheters,Proprietary laser bonded technology creates an extraordinary TrakTip Design and precise, smooth bonds throughout the shaft. Push coil design and improved distal flexibility for enhanced trackability. Our 1.5 and 2.0 mm SoftLEAP Balloons offer

5、 enhanced crossability.,Apex PTCA Dilatation Catheter,Slope Outer Shaft smoothly transitions from stiff to flexible, all in one piece, for more efficient push transmission Bi-Segment Inner Shaft optimizes the balance between push and track Shorter, thinner marker bands increase distal flexibility Re

6、designed tip with improved flexibility and wire movement; same ultra-low 0.017 profile OptiLEAP Balloon with reduced waist thickness provides great sizing flexibility with lower profiles Nano-composite materials adds structure and pushability to the outer shaft,Quantum Maverick Balloon,Low profile,

7、full length 1.8F or 2.0F Monorail shaft Low profile 3.2F proximal over-the-wire shaft Bioslide Coating on a PEBAX Distal Shaft Laser bonding technology Quantum LEAP Balloon Material Tapered TrakTip Design with .017 lesion entry profile*,Quantum Maverick Balloon,NC sprinter,外形细小的FasTrac头端技术-可在遇到 较难通过

8、的病变时提供极佳的通过能力； 柔软耐用的Fulcrum Plus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。,Sunflex Tip is superbly engineered to give a perfect balance between flexibility and kink resistance.

9、 Zero transition between the tip and wire for smoothest entry profile. Tapered Tip:The tapered soft tip combined with advanced laser welding technology provides the most competitive tip profile Slidematrix dual coating is specially formulated with two unique proprietary blends. Hydrophilic and Invio

10、 coatings are applied to the distal leading tip section and the balloon/shaft section, respectively to provide an optimal balance between lubricious crossing and minimizing watermelon seeding Tight Fold processing results in a slender primary profile for enhanced crossability through tight lesions.

11、Sapphire NC,OrbusNeich,The IP Transition Zone of the Avita PTCA Dilatation Catheter provides intensified pushability. The new tapered tip design with soft material exhibits a flexible tip for smooth lesion entry and minimal vessel trauma. The Invio coating on the inner lumen eliminates friction betw

12、een the catheter and guidewire. Invio is also applied to the outer distal segment from the tip to the exit marker zone for lubricious crossability. Avita HP,OrbusNeich,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

13、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Ryugin CrossTip 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(Flexible Corrugate) 轴管成为连接高弹性的前端轴管和具备强硬金属的Hypotube

14、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。,Voyager,Superb Cross Tapered Tip Design New tapered tip with .017” tip entry profile designed to cross tight lesions Improved tip-to-wire conformability1 for confident track and cross Polyurethane tip material is flexible yet durable for toug

15、h lesions Flexible tungsten marker technology allows catheter to conform to tortuous anatomy More Options Low Profile Shaft Design Versatile treatment in a 6F guide Excellent track and push in tortuous anatomy with new hypotube design Reinforced mid-shaft design provides flexibility and additional s

16、upport Flexibility with Visibility Proprietary Tungsten Marker New marker material comprised of tungsten polymer Flexible marker design allows the catheter to conform more easily to tortuous anatomy Increased marker flexibility helps to reduce resistance when crossing tight lesions Precise Dilatatio

17、n Proven Balloon Performance Short tapers allow for precise dilatation Improved LOFOLD Balloon Technology processes allows for excellent rewrap and recross1 XCELON S Balloon Material achieves superb flexibility,Powersail,PLATEAU Balloon Material Provides non-compliance at high pressure without compr

18、omising performance Flexibility and conformability for excellent deliverability LOFOLD Balloon Technology Provides a low crossing profile for exceptional lesion cross LOFOLD balloon technology for improved balloon rewrap Soft Tip Design Tapered tip design creates a low entry profile and excellent ti

19、p-to-wire conformability for easy lesion access Soft tip provides flexibility for negotiating tortuosity and crossing stent struts Dual Swaged Markers Provide lower profiles than conventional markers,SafeCut uses dual wire mechanism to create focused force. It has a built-in 0.011 integral wire exte

20、rnal to the balloon to help track tortuous vessels with great efficiency. A standard 0.014 guidewire that delivers the catheter to the target lesion also participates in the dilatation process. The guidewire exit port is located at the proximal part of the balloon. During balloon dilatation, the sta

21、ndard guidewire and integral wire apply controlled force to facilitate plaque fractures at low inflation pressures. The same application also helps minimize balloon slippage. SafeCuts distal leading tip profile is 0.032 tapered to 0.028 which is smaller than those of other focused force balloons. Ba

22、lloons with embedded blades for scoring the vessel have high crossing profiles due to the nature of the balloon materials and blades. The integral wire and standard guidewire apply evenly distributed force to facilitate controlled plaque at low pressures, reducing trauma to the vessel wall. Other ba

23、lloons using the same focused force technology use blades which are much more traumatic to the vessel wall.,OrbusNeich,Cutting Balloon,The Flexibility You Want Nylon balloon material designed to provide flexibility, superb compliance and improved puncture resistance Overall better deliverability to

24、treat more complex lesions. The Deliverability You Need 30% more Deliverable than the Cutting Balloon Ultra2 Device* 50% improvement in re-cross compared to the Cutting Balloon Ultra2 Device* The Predictability You Rely On Precise dilatation Scoring the plaque by severing the elastic and fibrotic co

25、ntinuity of the vessel wall Dilating the lesion at lower pressures with less recoil Lumen gain through plaque compression instead of vessel wall expansion,冠状动脉介入治疗支架的选择,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,支架分类

26、,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,支架的性能特点,支架的开环和闭环设计,网眼大小,微米,支架丝厚度,金属动脉比值,支架可视性,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，

27、多个支架不可避免时应可能减少支架过多重叠,Cordis Confidential - Internal Use Only,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,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

28、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。,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。,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,Recommendation,原位病变（De Novo）,ACC/AHA 2005 Guideline for PCI,ACC/AHA 2005 G

29、uideline for PCI,-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provisional DES) - 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,ACC/AHA 2005 Guideline for PCI,ACC/AHA 2007 guideline update for PCI,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

30、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（cutting balloon 或 safecut） 直接支架,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=1.1:1 IVUS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）,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3-5mm IVUS和带有标记的引导钢丝对于选择药物

31、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,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,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)

32、 后扩张球囊大小不应超过两个数量级,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,目前常用的药物支架特点,CYPHER Sirolimus-eluting Coronary Stent,TAXUS Express Coronary Stent,A Proven

33、Stent The Express2 Stent platform offers excellent deliverability and conformability. A Reliable Polymer The TAXUS Express Stent uses Translute Polymer, a proprietary polymer carrier technology, to control drug release. An Effective Drug The unique properties of paclitaxel contribute to the efficacy

34、 of the TAXUS Express Stent. Paclitaxels multi-functional effects, stabilize microtubules and inhibit activities that contribute to restenosis.3 Paclitaxel is highly lipophilic, which may contribute to more uniform drug distribution.4,316L 不锈钢材料 支架梁厚度 0.0038” 尖端外廓 0.017” 通过外廓 0.047”*,Pictures taken

35、by Boston Scientific.,改善的通过性*,*For a 3.0mm stent,Pictures taken by Boston Scientific.,*Based on internal bench tests of the features of the Libert Stent compared to Express Stent and market research results. Data on file.,TAXUS Libert 支架系统改善的输送性和顺应性,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

36、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 *,Picture taken by Boston Scientific.,*Based on internal bench tests of the features of the Libert Stent compared to Express Stent and market research results. Data on file.,TAXUS Libert 支架系统改善的输送性和顺应性,支架平台比较血管覆盖,TAXUS Libert 支架,TAXUS Libert 支架的小的单元面积设计可以保持出色

37、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,* Cell area variability based upon stent diameter. Images taken taken by Boston Scientific of 3.0mm diameter stents. Cypher is a trademark of Cordis Corp. Driver is a trademark of Medtronic/AVE.,Cypher Select 支架,Driver 支架,命名压力,额定爆破压力,命名压力,TAXUS Liber

38、t 支架系统 支架顺应性图表,ATM直径 (mm) 2.252.502.753.03.5 82.762.973.43 92.192.442.813.023.49 102.242.492.873.083.56 112.292.552.933.143.63 122.322.592.983.193.68 132.362.643.023.233.73 14 2.392.673.063.273.78 152.422.703.093.313.81 162.442.743.123.343.85 172.742.763.143.373.88 2.492.793.173.393.92,Nominal pressure for TAXUS Express2 : 9 A