冠脉分叉病变介入技巧

分叉病变介入技巧ClassificationofbifurcationlesionsaccordingtoplaqueburdenA:DukeB:SanbornC:SafianD:LefevreMedinaA.etal.RevEspCardiol.2006;59:183-4ANewClassificationofCoronaryBifurcationLesions-MedinaClassification1,1,11,1,01,0,10,1,11,0,00,1,00,0,1MBDistalMBProximalSB一个好还是两个好？如果选２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(especiallyMI/thrombosis)分叉病变介入治疗

-关注热点Stentingforbifurcationlesionsin2007主支放支架，分支临时决定StentingthemainvesselwithprovisionalstentingofthesidebranchProvisionalStentingStrategy

If2ndstentisneededforsidebranchfollowingmainvesselstentingModifiedT-stentingReversecrushing Culottestenting 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SidebranchclosureafterPCISide-branchmaybecompromisedfollowingmainvesselstentingPre-treatmentAfterstentingPlaqueshifting(“Snow-plow”)OstialspasmorSide-branchcompromisebystentmaterialDissectionofplaqueatoriginofside-branchDissectionflapatmainarteryobstructingoriginofside-branchAttimes,thesidebranchcouldbecompromisedbythrombustooDifferenttechniquesoftwostentsbyintentiontotreatbifurcationlesionsTheVstentingtechniqueThesimultaneouskissingstentstechniqueTheVstentingandthesimultaneouskissingstentingtechnique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。

TheVstentingandthesimultaneouskissingstentingtechnique优点:保证不会丢失分支。

对吻技术时无须re-crossanystent.TheVstentingandthesimultaneouskissingstentingtechnique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agap。TheTstentingtechniqueThemodifiedTstentingtechniqueTheTandmodifiedTstentingtechnique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。ColomboetalCirculation2004;109:1244-1249*Highcross-overratefromStent+BalloontoStent+Stentgroup(22/43,51%)CypherBifurcationStenting(T-stenting)EffectsoftheTstentingtechniqueRESEARCHbifurcationsubgroupRRofdifferenttechniquesThehighrestenosisrateofTstentingtechniquemayberelatedtotheincompletecoverageofstentingbeinglocatedattheostiumofSB.TanabeK,HoyeA,LemosPA,etal.AmJCardiol,2004,91:115-8EffectsoftheTstentingtechniqueVstentingvsTstentingSharmaetal.Vstenting:100ProvisionalTstenting:10032%subjectsreceivedCypherstentandRVDwas3.32mm。ProvisionalTstenting优点:HigherproceduralsuccessrateLowerexpenseLowercomplicationsLowerre-PCI7monsTLR<15%。Lefevreetal:ProvisionalTstentingisthegoldenstandardtotreatfalsebifurcationlesion(tpye2,3and4a),mostsubjectsonlyneedonestentimplantation。ProvisionalTstentingThecrushtechniqueThecrushtechnique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。Geetal.JACC2005;46:613Longtermoutcomeof“Crush”Stentingtechnique6monsRRColomboetal.ThecrushtechniqueThereversecrushorinternalcrushtechniqueThereversecrushorinternalcrushtechnique主要用于临时分支支架植入provisionalSBstenting.

Thereversecrushorinternalcrushtechnique

优点:可以保证两条分支的立刻开通，6Fguidingcatheter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。ThestepcrushtechniquedoublekissingCase:ThestepcrushtechniqueFirstkissingSecondkissingFinalresultThestepcrushtechnique优点:6Fguidingcatheter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thestandardcrushtechnique.TheinvertedcrushtechniqueTheinvertedcrushtechnique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thestandardcrushtechnique.RestenosisinMV=12.2%RestenosisinSB=2%Galassietal.Cath&Cardiovas.Intervn2007;69:976-83TheculottesstentingtechniqueTheculottesstentingtechnique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架重叠，金属密度高。NordicBifurcationStudyII-TheNordicStentTechniqueStudy:CrushvsCulottestentingNordicBifurcationStudyII-TheNordicStentTechniqueStudy:CrushvsCulottestentingIndividualend-pointat6monthsTheYstentingtechniqueTheskirttechniqueTheYstentingtechnique

andTheskirttechnique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TheYstentingtechnique77casebeingwithbifurcationlesionsreceivedtheYstentingtherapyand6monsfollow-upresults:RR36%,TLR30%。MaillardL,GuerinL,Drie