分叉病变介入技巧PPT课件

1、分叉病变介入技巧分叉病变介入技巧 Classification of bifurcation lesions according to plaque burden A:Duke B:Sanborn C:Safian D:Lefevre Medina A. et al. Rev Esp Cardiol. 2006; 59: 183-4 A New Classification of Coronary Bifurcation Lesions - Medina Classification 1, 1, 11 , 1, 01, 0 , 1 0, 1, 1 1, 0, 00, 1, 0 0, 0, 1

2、MB Distal MB Proximal SB 一个好还是两个好？ 如果选个，应该采取何种策略 ? 策略选择的根据 简单化 vs 复杂化 循证结果 vs 个人选择 并发症率 (especially MI / thrombosis) 分叉病变介入治疗 - 关注热点 Provisional Stenting Strategy If 2nd stent is needed for side branch following main vessel stenting Modified T-stenting Reverse crushing Culotte stenting 分支血管的保护与放置支架

3、并非所有分支血管同等重要! 根据以下情况实施分支血管保护和支架植入 分支血管大小与分布区域 分支血管开口病变与病变程度 分支与主支成角程度 Side branch closure after PCI Side-branch may be compromised following main vessel stenting Pre-treatment After stenting Plaque shifting (“Snow-plow”) Ostial spasm or Side-branch compromise by stent material Dissection of plaque a

4、t origin of side-branch Dissection flap at main artery obstructing origin of side-branch At times, the side branch could be compromised by thrombus too Different techniques of two stents by intention to treat bifurcation lesions The V stenting technique The simultaneous kissing stents technique The

5、T stenting and modified T stenting technique The crush technique(The reverse crush technique/The step crush technique/The inverted crush technique) The culottes stenting technique The Y stenting technique The skirt technique The V stenting technique The simultaneous kissing stents technique The V st

6、enting and the simultaneous kissing stenting technique 适合于分叉病变位于接近开口的血管近端，例如位于左主干的分叉病变，并且 左主干短或无病变。理想夹角90。 V支架也适合于其他部位的分叉病变，近段无病变或无须支架。 The V stenting and the simultaneous kissing stenting technique 优点: 保证不会丢失分支。 对吻技术时无须对吻技术时无须 re-cross any stent. The V stenting and the simultaneous kissing stenting

7、 technique 缺点: 双支架近端定位较困难； 不可避免造成其中一个支架偏心，往往引起 a gap。 The T stenting technique The modified T stenting technique The T and modified T stenting technique 优点: 较crush 技术容易完成。 缺点: 大多数情况下，分支开口不能完全覆盖。 Effects of the T stenting technique RESEARCH bifurcation subgroup RR of different techniques The high res

8、tenosis rate of T stenting technique may be related to the incomplete coverage of stenting being located at the ostium of SB. Tanabe K, Hoye A, Lemos PA, et al. Am J Cardiol, 2004, 91:115-8 Effects of the T stenting technique V stenting vs T stenting 1.5% 19.5% 2.0% 5.2% 0% 5% 10% 15% 20% 25% ST9 mo

9、ns TLR T stenting V stenting P=0.007 Sharma et al. V stenting:100 Provisional T stenting: 100 32% subjects received Cypher stent and RVD was 3.32mm。 Provisional T stenting 优点: Higher procedural success rate Lower expense Lower complications Lower re-PCI 7mons TLR 15%。 Lefevre et al: Provisional T st

10、enting is the golden standard to treat false bifurcation lesion(tpye2, 3 and 4a), most subjects only need one stent implantation。 Provisional T stenting The crush technique The crush technique 优点: 可以保证两条分支的立刻开通,这点对保护功能上重要 的分支非常重要。 可以完全覆盖分支开口。 缺点: 由于有多层支架金属，导丝和球囊再次通过较困难，操 作复杂。 Ge et al. JACC 2005; 46

11、: 613 Long term outcome of “Crush”Stenting technique 7.1% 12.5% 5.5% 35.0% 0% 10% 20% 30% 40% MBMBSBSB FKBnon-FKB P =0.11 6 mons RR Colombo et al. The crush technique The reverse crush or internal crush technique The reverse crush or internal crush technique 主要用于临时分支支架植入provisional SB stenting. The

12、reverse crush or internal crush technique 优点: 可以保证两条分支的立刻开通，6F guiding catheter可以完成操作。 缺点: 由于有多层支架金属，导丝和球囊再次通过较困难， 操作复杂。 The step crush technique Case: The step crush technique First kissing Second kissing Final result The step crush technique 优点: 6F guiding catheter可以完成操作，特别适合于 桡动脉经路，第二次导丝和球囊再次通过较容

13、易成 功。 缺点: 同 the standard crush technique. The inverted crush technique The inverted crush technique 适用于分支管径不小于主支的情况。 分支支架挤压crush主支支架。 缺点: 同 the standard crush technique. Restenosis in MV = 12.2% Restenosis in SB = 2% The culottes stenting technique The culottes stenting technique 优点: 适合于任何角度的分叉病变，并提

14、供完美的分支开口覆盖。 缺点: 分叉病变近段双层支架重叠，金属密度高。 Individual end-point at 6 months The Y stenting technique The skirt technique The Y stenting technique and The skirt technique 优点: 这是最后一种治疗分叉病变的方法，适用于非 常复杂的分叉病变并要求保证导丝进入两分支。 缺点: 近端支架释放系统需要改良，手工将支架捻在 双球囊上。应用DES易破坏polymer 。 近端支架很难完全连接远端双支架。 采用采用Y 支架技术时，多数术者将分支导丝回撤支架

15、技术时，多数术者将分支导丝回撤 并放入主支，这时释放近端支架可以更好并放入主支，这时释放近端支架可以更好连接 远端支架 The Y stenting technique 77 case being with bifurcation lesions received the Y stenting therapy and 6 mons follow-up results:RR 36%, TLR 30%。 Maillard L, Guerin L, Drieu L, et al. Am J Cardiol 1998;82:7A50S Classification of bifurcation les

16、ions according to plaque burden A:Duke B:Sanborn C:Safian D:Lefevre o The V stenting technique o The simultaneous kissing stents technique o The T stenting and modified T stenting technique o The crush technique(The reverse crush technique/The step crush technique/The inverted crush technique) o The

17、 culottes stenting technique Each lesion must be approached therapeutically in the context of its own anatomy. 一个好还是两个好？ 如果选个，应该采取何种策略 ? 策略选择的根据 简单化 vs 复杂化 循证结果 vs 个人选择 并发症率 (especially MI / thrombosis) 分叉病变介入治疗 - 关注热点 The V stenting technique The T and modified T stenting technique 优点: 较crush 技术容易完成。 缺点: 大多数情况下，分支开口不能完全覆盖。 V stenting vs T stenting 1.5% 19.5% 2.0% 5.2% 0% 5% 10% 15% 20% 25% ST9 m