动脉桥血管病变的PCI治疗.ppt

1、动脉桥血管病变的PCI治疗,上海交通大学医学院附属仁济医院 张 清,现 况,桥血管病变是指CABG后的动脉或静脉血管因粥样硬化、血栓形成或进行性退变而导致管腔狭窄或阻塞； 美国CABG例数30万例/年，桥血管介入10万例/年，占总PCI的1/10； 中国桥血管介入例数较少，近年搭桥例数约1万例/年，预计未来几年中国桥血管病变和介入数目将有明显增加,动脉桥病变,动脉桥较少发生内膜增生和粥样硬化，10年通畅率可达 90-95%； 30天内偶有血栓形成，多与操作技术有关； 粥样硬化偶有发生于动脉桥，动脉桥远端发生率相对较高； 评价动脉桥时需注意同时评价锁骨下动脉狭窄情况；,桥血管病变再次血运重建策略

2、,再次CABG PCI干预桥血管 PCI干预原位血管,再次CABG,全身情况差，手术死亡率高达3-10，围术期心肌梗死发生率高达 4-11.5； 术中有可能损伤开通的内乳动脉，导致心肌缺血加重和心肌功能受损； 再次CABG静脉桥血管通畅率低，5年仅为65； 未完全闭塞的自身血管血流压力较高，其对冲血流导致桥血管血流变慢，进而导致桥血管闭塞。再次CABG后的桥血管面临同样情况； 以上因素均使再次CABG术后心绞痛缓解率低，手术风险显著增高（再次CABG的风险较首次CABG高2-3倍），长期疗效不佳。 另外，少数已接受2次或以上CABG的患者因桥血管供体有限，很难从自身进一步提供桥血管来源，也使再

3、次行CABG术受到很大限制,桥血管介入治疗-AWESOME,5年多中心随机临床研究，美国16家退伍军人协会医疗中心，2431例 ； 药物难治的心肌缺血 ，既往心脏手术、70岁、LVEF0.35、7天内MI、需要IABP等5个危险因素中的1个或多个因素存在 ； 三种分组方式：随机分组、医生安排患者选择治疗方式、患者自行选择治疗方式,AWESOME,142/454,719/1650,119/327,提示对CABG术后患者而言，应优先采用PCI 而不是CABG进行再次血运重建治疗,桥血管PCI的优势及问题,创伤小、围手术期安全、手术难度相对小、疗效优于二次CABG； 但桥血管病变多为弥漫性易碎斑块，

4、PCI术中易远端栓塞，再次MI危险大； 再狭窄率高（80%），长期疗效不佳（5年无MACE40-59%）,原位血管PCI,问题：全身状态差、合并症多、病变多支、复杂，自身血管PCI危险性高、难度大； 复杂PCI成功率提高，DES应用降低再狭窄率，处理、开通原位血管成为可能； 优势：部分桥血管开通，提供部分心肌保护，提高PCI安全性；经开通的桥血管逆向操作，提高PCI成功率； 1年内MACE，26%非靶病变；3年MACE，46%非靶病变持续进展,CABG后策略,优先考虑PCI，后考虑再次CABG； 选择PCI策略后，优先考虑原位血管？还是考虑桥血管？ 个体化方案,桥血管PCI指征建议,(1) S

5、VG-PCI术时，采用远端保护装置(I，A)； (2) CABG后3个月出现缺血，可行桥血管PCI(I，A)； (3) 因桥血管孤立病变导致CABG后1-3年后出现缺血症状或有相关缺血证据，行桥血管PCI(IIa，c)； (4) 内乳动脉桥通畅，行其他自身闭塞血管PCI(II a，c)； (5) 慢性闭塞SVG，不推荐行PCI(III，B)； (6) CABG后多支血管病变伴多支桥血管功能丧失，不推荐行PCI(III，B)。,Different types of arterial conduits,Autologous: Left internal mammary artery (LIMA),

6、 right internal mammary artery (RIMA), right gastroepiploic artery (RGEA), inferior epigastric artery (IEA), radial artery (RA), splenic artery, gastroduodenal artery, left gastric artery, and intercostal artery Nonautologous: Bovine IMA,Total arterial revascularization with BITA,RA and GEA,Differen

7、t types of arterial graft,Different types of arterial graft,Right GastroEpiploic Artery,RGEA anastomosed to RCA 26:114-24,BITA grafts are superior to a SITA graft,Ann Thorac Surg 2004;78:2005214.,RA areprone to intimal hyperplasia,Circulation 1999;100(Suppl. II):13944.,RA patency varied widely,Eur J

8、 Cardiothorac Surg 2006;30(August):3416.,RGEA patency was similar to SVG,Circulation 2007;116(September (11 Suppl.):I18891.,Obstructive lesions in arterial grafts,Several hypotheses have been put forward to explain the presence of obstructive lesions in radial grafts: competitive flow from native ci

9、rculation intimal hyperplasia endothelial injury during manipulation of the graft technical problems during surgery,Arterial graft stenosis(1),In the largest series of PCIs performed in radial grafts, it was found that two-thirds of cases of radial graft stenosis occur at the proximal and distal ana

10、stomoses The same is true for IMA grafts, suggesting that the main origin of stenosis in these patients is related to technical difficulties Cathet Cardiovasc Diagn. 2003; 59:172-5.,Arterial graft stenosis(2),In our patient, stenosis was probably linked to intimal hyperplasia, based on the location

11、of the lesion in the proximal third of the graft and the time window of more than 1 year between surgery and the onset of symptoms. Rev Esp Cardiol. 2005;58:306-9.,Arterial graft stenosis(3),Arterial grafts are used in diabetic patients and there is a potentially high risk of restenosis following PC

12、I, the use of Drug Eluting Stents may play an important role in these procedures Circulation. 2004;109:634-40.,PCI of theanastomosis of LIMA to LAD,In cases of stent implantation at the coronary LIMA graft anastomosis angioplasty site, the restenosis rate was 80%, but it was only 14% in cases of pur

13、e balloon dilation (p = 0.001). Am J Cardiol. 2004 Jun 15;93(12):1531-3 Angiographic follow-up of ten stenting patients revealed a restenosis rate of 20% (2/10). The mean clinical follow-up duration was 34.5 +/- 20.9 months. Chang Gung Med J. 2007 May-Jun;30(3):235-41,PCI of theanastomosis of LIMA t

14、o LAD,Coronary Artery Disease 2007, Vol 18 No 6,PCI of theanastomosis of LIMA to LAD,PCI of the stenoses of LIMA-to-LAD anastomoses with DES did not provide any clinical improvement over BMS use in long-term outcomes; DES use was associated with some cases of late thrombosis. Coronary Artery Disease

15、 2007, Vol 18 No 6,动脉桥血管介入的介入体位选择,靶病变位于LIMA的近端或体部：RAO 30+Caudal 30 靶病变位于LIMA的远端或吻合口部： LAO 50+Cranial 30 RA to RCA 靶病变在桥血管近端：RAO 靶病变在桥血管远端：AP+Cranial RA to LCX 靶病变在桥血管近端：LAO+Cranial 靶病变在桥血管远端：RAO+Caudal RGEA AP+Cranial,Catheters for graft angiography and intervention,The most commonly used catheters

16、for coronary arteries, vein and arterial graft angiography and interventions: Left : pigtail, Judkins right 4, and Judkins left 4 . Right: Amplatz Left 1, 2 and 3, and multipurpose catheter.,LIMA catheter for left IMA,Selective angiography of the left IMA is performed using a LIMA catheter.,JR4 for

17、RIMA,A non-selective angiography of the right IMA is performed using Judkins right 4.,LIMA to LAD,RAO,LAO,LIMA to Diagonal,RAO,RAO+Caudal,RIMA to LAD & RCA,RAO,LAO+Cranial,RGEA to RCA,AP+Cranial,ISR in RGEA graft,ISR in RGEA graft,PCI of Radial Arterial grafts,PCI of Radial Arterial grafts,动脉桥血管病变PC

18、I的技术细节,Guiding Catheter的选择： 经LIMA的指引导管有专用的导管，其前端弯度比JR稍大，使其更容易选择性进入内乳动脉开口，但也更易导致开口损伤，操作时宜轻柔。其他动脉桥血管可选JR4为主。 Guidewire的选择： 取决于病变的部位，病变远端血管的弯曲度，以及病变的性质等。需要通过动脉桥处理吻合口远端的自身血管病变的也常见，此时远端血管如果扭曲，则选择亲水涂层的钢丝。如果远端血管扭曲，病变在扭曲的远端，则考虑选用超强支撑力的Extrasupport导丝。,动脉桥血管病变PCI的技术细节,Balloon 的选择： 以选择非顺应性的球囊，球囊直径不宜过大，与远端血管的比例以1:1为宜。不宜在病变未充分扩张时植入不能充分张开的支架。 S