开口及分叉病变

1、开口及分叉处病变北京大学第一医院霍勇开口处病变Ostial Lesion ClassificationAorto ostialBranch OstialOstial Lesion ClassificationOstial Lesion ClassificationJunction between the aorta and orifice of the RCA, SVG, or LMJunction between a large epicardial vessel and its branch; als乡: called rigirT lesionAorto-Ostial Lesions:

2、GuidingCatheter SelectionThe key to success is co-axial alignment, not a “power positionRemember that sidehole guides will permit passive perfusion and reduce pressure damping and ischemia, but do NOT prevent vessel injury.Aorto-Ostial Lesions: GuidingMCatheter Tech niqueImproper Technique:Balloon i

3、nflated in guiding catheter I +ling caAorto-Ostial PTCA: Watermelon-edingSOLUTION:Long balloons (30-40 mm)Cutting balloonRotablator (calcified lesions)Approach to Aorto-Ostial Lesions(No calcification)Vessel 2.5 mmRotablatorCutting balloonPTCARotablatorCutting balloonPTCA or DCADESDESApproach to Aor

4、to-Ostial Lesions(Sig nifica nt calcificatio n)Consider IVUS for sizing,assessment of extent of Ca+1卩RotablatorDES* Cutting balloon is not a suitable substitute for most calcified stenoses.Aorto-Ostial Lesions: DCAProper technique requires gentle retraction of the guiding catheter 2-3 cm into the ao

5、rta prior to cutter activation .It is important to establish other landmarks (rib margins, catheter shaft) to ensure precise positioning of the AtheroCath Failure to retract the guide may result in oartial excision of the tip of the auide durina cutter activation.Aorto-Ostial Lesions: RotablatorProp

6、er technique involves selection of a guiding catheter that provides ideal coaxial alignment and use of a Rotablator support guidewire After crossing the lesion with the guidewire, allow the guide to gently “kick- out” of the ostium to facilitate ablation of the ostial lesion. The platform speed shou

7、ld be adjusted in the guiding catheter. Remove all slack in the guidewire to avoid kinking at the ostium.Aorto-Ostial Lesions: StentA. Position the stent-delivery balloon so 1 mm of stent extends into the aorta. The guide must be retracted cm before deploying the stent.B. After stent deployment, rem

8、ove the delivery balloon while maintaining backward tension on the guide to prevent it from advancing into the ostium and damaging the stent.C. Perform adjunctive PTCA with a high pressure balloon; consider IVUS to ensure full stent expansion and apposition. Flaring the proximal end of the stent wit

9、h a slightly larger balloon is useful.POST ROTA/PTCAAorto-Ostial Lesions: SVG to LADPREPOSTBranch-Ostial Lesions: DiagonalBranchBranch-Ostial Lesions: Origin LADPOST-DCA分叉处病变Bifurcation Lesions: Risk ofSidebranch Occlusion (SBO)Bifurcation lesion has been a predictor ofworse prognosis of PCI.Event-f

10、ree survival after BMS implantation in NHLBI RegistryDuration (months)AnatomySBO (%) SB ProtectionBranch normal, originates 50%， originates from target lesion2 -10 Yes, for large branches15-35 YesClassification of BifurcationLesionsClassification of BifurcationLesionsTYPE 1: Parent vesselstenosis pr

11、oximal andSidebranch involved(True bifurcation lesion)Sidebranch normalClassification of BifurcationLesionsSidebranch involvedSidebranch normalTYPE 2: Parent vessel stenosis proximal to bifurcationClassification of BifurcationLesionsSidebranch involvedSidebranchnormalTYPE 3: Parent vessel stenosis d

12、istal to bifurcationClassification of BifurcationLesionsTYPE 4: Parent vessel is normal; Ostial sidebranch stenosisPCI TechniqueSimple vs- ComplexSimple Stenting Technique1. Stent placement in the main branch onlyAnd1) Optional kissing balloon inflation2) Provisional T stenting3) Provisional reverse

13、 Crush techniqueStenting Crossing Side BranchWith Optional Kissing Balloon InflationNormal or diminutive side branch ostiumABCDLAD Bifurcation Lesion withNormal Diagonal OstiumMain vesselJailed Diagonal Branch afterCypher (3.5 23mm) ImplantationKissing Balloon Inflation and Good ResultProvisional T

14、StentingIn cases with significant narrowing ofside branch after main branch stentingABCDLimitation of Modified T StentingRestenosis site of T stenting in SIRIUS bifurcationPotential gap withoutTo prevent potential gap at the ostial side branch, the first stentshould cover the entire surface of the s

15、ide branch.True LAD Bifurcation StenosisCypher Stenting (3.5x23mm) andKissing Balloon Inflation. However.Side Branch Stenting witha Cypher (2.75 x 13mm) and Kissing BalloonGood ResultModified T StentingCrush TechniqueProximal location of the stent in the main vessel ABCMain vessel“Internal or Revers

16、e51 Crushallows provisional SB stenting with full ostial coverageABCDBalloon“Internal” or “Reverse” CrushThis technique allows provisional stenting of the side-branch with a fall-back strategy that delivers coverage of the side-branch ostium without gaps.Final kissing balloon inflation may be diffic

17、ult because a balloon should be crossed through the crushed stent segment in the side branch ostium.Modification in big side branchPioximal location of thestent in the side branchABCDMain vesselOne More Step of Crush TechniqueFinal Kissing Balloon Dilatationfor side branch re-opening and stent optim

18、izationEFGRe-advancement of wire into the side branchOpening of the Final kissing side branch ostiumballoon inflationTrue LAD Bifurcation StenosisCrushing with two Cyphers(3.5x23mm in LAD & 2.5x18mm in Diag)Balloon Dilatation in Diag &Final Kissing Balloon InflationMaverick 2.5x20mm balloonMaverick

19、2.5x20mmStent balloon 3.5x25mmCrush and Kissing Balloonwith Cypher in MATRIX Registry108 patients, April 2003 Nov. 2003In- hospital events No death, MI, CABG, urgent TLR30- day outcome No death Stent thrombosis1.9 % (2/108)Intermediate- term clinical outcome No death, MI TLR12 % (9/108)I Moussa f A

20、CC 2004Benefit of Final Kissing InflationClinical Outcome at 6 MonthsRestenosisTLRA Colombo, ACC 2004Side branch No final kissingP0.001203Main vessel Final kissing0.66P50%)25.3%27.6%Acute gain in-stent (mm)1.36 0.46Late loss in-stent (mm)0.84 0.55OBFrontier Registry: QCA AnalysisSide Branch In-segmentTotal(n = 96)Stented (n = 39)Ballooned (n = 36)Non-treated(n-21)Pre-procedure ref. diameter (mm)2.10 + 0.672.32 + 0.792.01 0.531.81+0.54Pre-procedure DS (%)39.1 + 18.146.7 19.437.0113.927.