CTO病变表现、介入治疗技巧和处理

1、CTO病变表现、介入治疗技巧和处理介入心脏医生的最后挑战CTOThe Final Frontiers 分叉病变 小血管病变 多支血管及/或弥漫性病变 慢性闭塞性病变(CTO)Multi-vessel disease with CTOCTO病变比率 30%70%Patients with TotalOcclusionsPatients withoutTotal OcclusionsSource: Cardiac Data Resources, The BLG Group30% of patients have one or more total occlusionsCTO病变血管再通的理论价值延

2、长生命 改善左室功能 增加心肌电活动稳定性，减少心律失常事件增加以后可能出现的冠状动脉闭塞事件耐受性减少CABG提高生活质量开通CTO的理由 生存率结果2,007 Consecutive CTO patients June 1980 December 1999 distinct 10-year survival advantage for successful CTO treatment compared to failed CTO treatment.(73.5% vs 65.1%, p=0.001) Suero et. al - JACC August 2001 开通CTO的理由 生存率结

3、果“At one year follow up, patients with successful PCI of a CTO had a significantly better clinical outcome than those whose PCI was unsuccessfulOlivari, et al., JACC May 21, 2003 At 12 months, patients with a successful CTO procedure experienced: Lower incidence of cardiac deaths or MIs (1.05% vs 7.

4、23%, p=0.005)Reduced need for CABG (2.45% vs 15.7%, p95%CTO病变的介入治疗成功率: 大约 60%The major determinant of success is passage of the guide wire across the lesion！CTO病变介入治疗技巧常见的失败原因容易成功病变（病例）的选择器械的选择方法的选择何时应该停止手术药物支架的效果并发症的处理CTO操作常见的失败原因导丝不能通过（85%） 包括不能穿透闭塞近端/远端纤维帽，进入假腔，或穿孔球囊不能通过（10）不能扩张病变（5）CTO病变介入治疗技巧常见

5、的失败原因容易成功病变（病例）的选择器械的选择方法的选择何时应该停止手术药物支架的效果并发症的处理CTO病变介入治疗成功失败的预测因素闭塞时间3个月对成功不利闭塞段血管长度15mm 对成功不利闭塞近端管状或鼠尾状VS齐头状齐头状使导丝侧滑对成功不利血管闭塞处存在侧支血管对成功不利桥侧支血管的形成对成功不利利于或不利于成功的CTO病变特征逆向造影显示闭塞远端显影良好易成功LAD闭塞处发出对角支不易成功对角支LAD闭塞的右冠发自左冠，侧支循环良好易成功闭塞段CTO近端重度扭曲并分叉不易成功闭塞处分支严重扭曲闭塞处LAD闭塞处发出对角支不易成功LAD闭塞处发出对角支不易成功对角支LAD侧支循环LAD

6、闭塞处右冠闭塞处不确切不易成功分支主干闭塞处？LAD闭塞侧支循环良好易成功前降支侧支循环显影闭塞段呈鼠尾状易成功闭塞段长，桥侧支血管形成不易成功桥侧支血管功能性闭塞易成功功能性闭塞段OM支功能性闭塞易成功桥侧支血管形成不易成功桥侧支血管的存在使导丝可能进入多条孔道不易成功Neo channels can lead through the stenosis or can connect with vasa-vasorum. Connections with vasa-vasorum more likely result in sub-intimal dissection or wire exit

7、对病变的了解不全面或技术没有完全掌握就可能给患者带来风险CTO病变介入治疗技巧常见的失败原因容易成功病变（病例）的选择器械的选择方法的选择何时应该停止手术药物支架的效果并发症的处理Amplatz指引导管增加支撑力，利于球囊通过闭塞段Amplatz(AL 1.0)指引导管时球囊不能通过闭塞的右冠发自左冠指引导管的选择6F EBU 3.5导丝的选择亲水涂层的PT2 LS1.5*15mm Over The Wire 球囊PT2 LS1.5mm Over The Wire 球囊 前降支开口处闭塞导丝的选择LAD闭塞处LCX导丝的选择：缠绕硬导丝Hydrophilic (slippery) wire t

8、ip has difficulty engaging entry point dimpleLow lubricity (spring coil) wireTip can more easily engage entry point dimple强支撑力指引导管6F EBU 3.5前降支开口处闭塞导丝的选择： CROSS-IT 200CROSS-IT 200Second and Third Generation WiresHydrophylicChoice-PT(BSC)PT SeriesStiff SpringMiracle Bros (Abbott)Cross-It (Guidant)Sti

9、ff HydrophylicShinobi (Cordis)PT Interm. (BSC)CTO介入治疗器械决定操作是否成功CTO病变介入治疗技巧常见的失败原因容易成功病变（病例）的选择器械的选择方法的选择何时应该停止手术药物支架的效果并发症的处理对侧造影能够显示导丝是否在血管真腔当第一根导丝进入夹层时：平行导丝技术平行导丝技术导丝在血管腔外平行导丝技术第二根导丝进入真腔2006-08-27 北京首都机场平行导丝技术要求的技巧远端管腔显影良好避免两条导丝缠绕建议使用头部性能好的导丝逆向导丝法逆向导丝法逆向导丝法球囊PT2-MS导丝（经左冠）BMW（经右冠）闭塞的LAD严重成角谁能进入前降支？

10、对角支前降支验证导丝是否在闭塞远端管腔内的方法：造影时回撤球囊可显示闭塞远端血管闭塞病变时应用OTW球囊进行锚定示意图闭塞病变扩张边支开口技术 球囊堵塞边支开口If guide wire consistently goes into the side branch - use a compliant balloon at low pressure to better direct guide wire导丝通过 CTO病变CTO病变介入治疗技巧常见的失败原因容易成功病变（病例）的选择器械的选择方法的选择何时应该停止手术药物支架的效果并发症的处理坚持、坚持、再坚持！但下列情况时STOP出现并发症（

11、大或小）造影剂用量过多（5001000CC）曝光时间过长（60min）手术时间过长（2-3小时)CTO病变介入治疗技巧常见的失败原因容易成功病变（病例）的选择器械的选择方法的选择何时应该停止手术药物支架的效果并发症的处理WISDOM 注册研究: Objective To evaluate the 12-month outcome of “real world” interventions using the paclitaxel-eluting TAXUS SR Express stent in high-risk patient and lesion subgroupsDiabeticsPa

12、tients with acute coronary syndromsTotal occlusionsLonger lesionsSmaller vesselsAim of the PRISON II Study To compare the immediate and long-term angiographic and clinical results of BMS (Bx Velocity) implantation with Sirolimus-eluting Stent (CYPHER) implantation for the treatment of CTO 6-month Cl

13、inical Follow-upClinical Event (%)204248228194320P=NSP=NS04136117%73%81%6 Month Angiographic Binary Restenosis Relative Risk Reduction6-month Angiographic Follow-up Binary Restenosis (50%)Note: * Stented segment including proximal and distal 5 mm4111367134*%(Stent) Thrombosis in Target VesselBMS (n=100)SES (n=100) In-hospital001-30 days01 (1%)30-180 days01 (1%)p=nsCTO病变介入治疗技巧常见的失败原因容易成功病变（病例）的选择器械的选择方法的选择何时应该停止手术药物支架的效果并发症的