分叉病变介入技巧课件

1、分叉病变介入技巧广东省人民医院谭 宁Classification of bifurcation lesions according to plaque burdenA:DukeB:SanbornC:SafianD:LefevreMedina A. et al. Rev Esp Cardiol. 2006; 59: 183-4A New Classification of Coronary Bifurcation Lesions- Medina Classification1, 1, 11 , 1, 01, 0 , 10, 1, 11, 0, 00, 1, 00, 0, 1MB DistalMB

2、 ProximalSB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 Stenting for bifurcation lesions in 2007主支放支架，分支临时决定Stenting the main vessel with provisional stenting of the side branch Provisional Stenting Strategy If 2nd stent is needed for side b

3、ranch following main vessel stenting Modified T-stenting Reverse crushing Culotte stenting分支血管的保护与放置支架 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Different techniques of two stents by intention to treat bifurcation lesionsThe V stenting techniqueThe simultaneous kissing ste

4、nts techniqueThe 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 techniqueThe Y stenting techniqueThe skirt techniqueThe V stenting techniqueThe simultaneous kissing stents techni

5、queThe T stenting techniqueThe modified T stenting techniqueThe 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。Colombo et al Circulation 2004; 109:1244-1249* High cross-over rate from Stent + Balloon to Stent + Stent group (22/43, 51%)Cypher Bifurcation Stenting ( T-stentin

6、g )Effects of the T stenting techniqueV stenting vs T stentingSharma et al.V stenting:100Provisional T stenting: 10032% subjects received Cypher stent and RVD was 3.32mm。Provisional T stenting优点:Higher procedural success rateLower expenseLower complicationsLower re-PCI7mons TLR 15%。Lefevre et al: Pr

7、ovisional T stenting is the golden standard to treat false bifurcation lesion(tpye2, 3 and 4a), most subjects only need one stent implantation。Provisional T stentingThe crush techniqueThe 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;

8、 46: 613Long term outcome of “Crush”Stenting technique 6 mons RR Colombo et al. The crush techniqueThe reverse crush or internal crush techniqueThe reverse crush or internal crush technique主要用于临时分支支架植入provisional SB stenting. The reverse crush or internal crush technique 优点:可以保证两条分支的立刻开通，6F guiding

9、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 techniquedouble kissingCase: The step crush techniqueFirst kissingSecond kissingFinal resultThe 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易成功。 缺点:同 the standard crush technique. The inverted crush technique

10、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%Galassi et al. Cath & Cardiovas. Intervn 2007; 69: 976-83The culottes stenting techniqueThe culottes stenting technique优点:适合于任何角度的分叉病变，并提供完美的分支开口覆盖。缺点:分叉病变近段双层支

11、架重叠，金属密度高。Nordic Bifurcation Study II- The Nordic Stent Technique Study: Crush vs Culotte stentingNordic Bifurcation Study II- The Nordic Stent Technique Study: Crush vs Culotte stentingIndividual end-point at 6 months The Y stenting techniqueThe skirt techniqueThe Y stenting technique and The skirt

12、 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Y 支架技术时，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连接远端支架The Y stenting technique77 case being with bifurcation lesions received the Y stenting therapy and 6 mons follow-up results:RR 36%, TLR 30%。

13、Maillard L, Guerin L, Drieu L, et al. Am J Cardiol 1998;82:7A50SClassification of bifurcation lesions according to plaque burdenA:DukeB:SanbornC:SafianD:LefevreThe V stenting techniqueThe simultaneous kissing stents techniqueThe T stenting and modified T stenting technique The crush technique(The reverse crus