阐述冠脉分叉病变介入技巧

1、阐述冠脉分叉病变介入技巧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 Proxi

2、malSB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 branch

3、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 PCISide-branch may be compromised following main vessel stentingPre-treatmentAfter stentingPlaque shifting(“

4、Snow-plow”)Ostial spasm orSide-branch compromise by stent materialDissection of plaque at origin of side-branchDissection flap at main artery obstructing origin of side-branchAt times, the side branch could be compromised by thrombus tooDifferent techniques of two stents by intention to treat bifurc

5、ation lesionsThe V stenting techniqueThe simultaneous kissing stents 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 techni

6、queThe V stenting techniqueThe simultaneous kissing stents techniqueThe V stenting and the simultaneous kissing stenting technique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。 The V stenting and the simultaneous kissing stenting technique优点:保证不会丢失分支。 对吻技术时无须 re-cross

7、 any stent. The V stenting and the simultaneous kissing stenting technique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 a gap。The 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

8、cross-over rate from Stent + Balloon to Stent + Stent group (22/43, 51%)Cypher Bifurcation Stenting ( T-stenting )Effects of the T stenting techniqueRESEARCH bifurcation subgroupRR of different techniquesThe high restenosis rate of T stenting technique may be related to the incomplete coverage of st

9、enting being located at the ostium of SB.Tanabe K, Hoye A, Lemos PA, et al. Am J Cardiol, 2004, 91:115-8Effects 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:High

10、er procedural success rateLower expenseLower complicationsLower re-PCI7mons 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 stentingThe crush techniqueThe crush techn

11、ique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; 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

12、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 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 cathete

13、r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 techniqueThe 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: 976-83Th

14、e 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 en

15、d-point at 6 months The Y stenting techniqueThe skirt techniqueThe Y stenting technique and The skirt 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 w

16、ith 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;82:7A50SClassification of bifurcation lesions according to plaque burdenA:DukeB:SanbornC:SafianD:LefevreThe V stenting techniqueThe simultaneous kissing stents techniqueThe T ste