分叉病变介入技巧

分叉病变介入技巧 广东省人民医院 谭 宁 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 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 Stenting for bifurcation lesions in 2007Stenting for bifurcation lesions in 2007 主支放支架，分支临时决定主支放支架，分支临时决定 StentingStenting the main vessel with the main vessel with provisional stenting of the side branch provisional stenting of the side branch 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 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 at 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 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 stenting and the simultaneous kissing stenting technique 适合于分叉病变变位于接近开口的血管近端 ，例如位于左主干的分叉病变变，并且左主 干短或无病变变。理想夹夹角90。 V支架也适合于其他部位的分叉病变变，近 段无病变变或无须须支架。 The V stenting and the simultaneous kissing stenting technique 优优点: 保证证不会丢丢失分支。 对吻技术时无须 re-cross any stent. The V stenting and the simultaneous kissing stenting technique 缺点: 双支架近端定位较较困难难； 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 优优点: 较较crush 技术术容易完成。 缺点: 大多数情况下，分支开口不能完全覆盖。 Colombo et al Circulation 2004; 109:1244-1249Colombo et al Circulation 2004; 109:1244-1249 * * High cross-over rate from Stent + Balloon to High cross-over rate from Stent + Balloon to Stent + Stent group (22/43, 51%) Stent + Stent group (22/43, 51%) Cypher Cypher Bifurcation Bifurcation StentingStenting ( T-stenting ) ( T-stenting ) Effects of the T stenting technique RESEARCH bifurcation subgroup RR of different techniques The high restenosis 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 Sharma et al. V stenting:100 Provisional T stenting: 100 32% subjects received Cypher stent and RVD was 3.32mm。 Provisional T stenting 优优点: Higher procedural success rate Lower expense Lower complications Lower re-PCI 7mons TLR 15%。 Lefevre et al: Provisional T stenting 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 优优点: 可以保证证两条分支的立刻开通,这这点对对保护护功能上重要的 分支非常重要。 可以完全覆盖分支开口。 缺点: 由于有多层层支架金属，导丝导丝 和球囊再次通过较过较 困难难，操 作复杂杂。 Ge et al. JACC 2005; 46: 613 Long term outcome of “Crush”Stenting technique 6 mons RR Colombo et al. The crush technique The reverse crush or internal crush technique The reverse crush or internal crush technique 主要用于临时临时 分支支架植入provisional SB stenting. The reverse crush or internal crush technique 优优点: 可以保证证两条分支的立刻开通，6F guiding catheter可 以完成操作。 缺点: 由于有多层层支架金属，导丝导丝 和球囊再次通过较过较 困难难， 操作复杂杂。 The step crush technique Case: The step crush technique First kissing Second kissing Final result The step crush technique 优优点: 6F guiding catheter可以完成操作，特别别适合于桡动桡动 脉 经经路，第二次导丝导丝 和球囊再次通过较过较 容易成功。 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。 分支支架挤压挤压 crush主支支架。 缺点: 同 the standard crush technique. Restenosis in MV = 12.2% Restenosis in SB = 2% GalassiGalassi et al. et al. CathCath 69: 976-83 2007; 69: 976-83 The culottes stenting technique The culottes stenting technique 优优点: 适合于任何角度的分叉病变变，并提供完美的 分支开口覆盖。 缺点: 分叉病变变近段双层层支架重叠，金属密度高。 Nordic Bifurcation Study IINordic Bifurcation Study II - The Nordic Stent Technique Study- The Nordic Stent Technique Study : Crush : Crush vsvs CulotteCulotte stenting stenting Nordic Bifurcation Study IINordic Bifurcation Study II - The Nordic Stent Technique Study- The Nordic Stent Technique Study : Crush : Crush vsvs CulotteCulotte stenting stenting Individual end-point at 6 months The Y stenting technique The skirt technique The Y stenting technique and The skirt technique 优优点: 这这是最后一种治疗疗分叉病变变的方法，适用于非常 复杂杂的分叉病变变并要求保证导丝进证导丝进 入两分支。 缺点: 近端支架释释放系统统需要改良，手工将支架捻在双 球囊上。应应用DES易破坏polymer 。 近端支架很难难完全连连接远远端双支架。 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连接远远端 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 lesions according to plaque burden A:Duke B:Sanborn C:Safian D:Lefevre oThe V stenting technique oThe simultaneous kiss