基础医学CTO病变的技巧冠心病最新进展课件

慢性完全闭塞病变介入技巧和器械选择北京安贞医院吕树铮教授1h慢性完全闭塞病变介入技巧和器械选择北京安贞医院1h慢性完全闭塞病变介入技巧和器械选择慢性完全闭塞病变的相关概念慢性完全闭塞病变的病理结构和特点CTO介入的导丝选择CTO病变的支架选择2h慢性完全闭塞病变介入技巧和器械选择慢性完全闭塞病变的相关概念CTO的定义闭塞时间大于3个月的病变3hCTO的定义闭塞时间大于3个月的病变3hCTO病变形成时间的判断AMI的时间症状加重的时间侧枝循环形成的多少及侧枝的直径4hCTO病变形成时间的判断AMI的时间4hCTO病变长度的判断顺行显影逆行显影双向造影5hCTO病变长度的判断顺行显影5h顺行显影6h顺行显影6h逆行显影7h逆行显影7hCTO病变的病理结构1.坏死脂核、胆固醇结晶及钙化8hCTO病变的病理结构1.坏死脂核、胆固醇结晶及钙化8hCTO病变的病理结构2.细胞外基质：胶原、钙化9hCTO病变的病理结构2.细胞外基质：胶原、钙化9hCTO病变的病理结构3.微血管10hCTO病变的病理结构3.微血管10hCTO病变的类型重度狭窄慢性闭塞轻中度狭窄慢性闭塞11hCTO病变的类型重度狭窄慢性闭塞11h重度狭窄慢性闭塞☺主要由纤维化和钙化的粥样硬化斑块组成☺短闭塞段：纤维帽位于闭塞段的两侧边缘，中间为血管壁重塑形成的组织，闭塞时间一般为3个月以上，重塑的组织中含有大量的纤维组织☺长闭塞段：常常有血栓的成分，闭塞段往往是纤维组织与血栓相间分布。这种病变导丝很难通过，成功率只有50～70%12h重度狭窄慢性闭塞☺主要由纤维化和钙化的粥样硬化斑块组成12h轻中度狭窄慢性闭塞脂核纤维组织陈旧血栓原有轻中度狭窄病变，班块破裂，未及时治疗，导致血管慢性闭塞，新的闭塞处远离原有狭窄斑块，导丝注意寻找闭塞斑块13h轻中度狭窄慢性闭塞脂核纤维组织陈旧血栓原有轻中度狭窄病变，班CTO病变的病理特点粥样斑块+钙化慢性发展融合而成14hCTO病变的病理特点粥样斑块+钙化慢性发展融合而成14hCTO病变的病理特点斑块破溃形成血栓机化而成15hCTO病变的病理特点斑块破溃形成血栓机化而成15hCTO介入的导丝选择16hCTO介入的导丝选择16h导丝的结构17h导丝的结构17h导引导丝的性能☺调节力：导丝尖端和中心钢丝结构☺柔软性：导丝的直径、尖端结构和连接段变系程度☺推送力：中心钢丝的硬度和中间变细方式☺支持力：中心钢丝的直径和材料18h导引导丝的性能☺调节力：导丝尖端和中心钢丝结构18h处理CTO病变时常用的导丝超滑导丝：如PTGraphicIntermediate、PT2、Shinobi、CrossNT、Whisper等Coil型导丝：ACSIntermediateStandard、CrossIT100-400、Miracle3-12及Conquest(Pro)9-12等19h处理CTO病变时常用的导丝超滑导丝：如PTGraphic处理CTO病变时常用导丝超滑导丝20h处理CTO病变时常用导丝超滑导丝20hSCIMEDPT221hSCIMEDPT221hThecombinationofapolymercoverandhydrophiliccoatingprovidesoutstandinglubricity.22hThecombinationofapolymercSCIMEDPTGraphicIntermediate

Uni-bodycorewithlong,smoothtaperfromsupportregiontotipHydrophilic-coated,polymersleeveandtipIntermediatewirewithslightlystiffertipCrossingperformanceofpolymertipwithvisibilityofspringtip23hSCIMEDPTGraphicIntermediateTerumoCrossNT24hTerumoCrossNT24hWHISPER™RedefinesPolymerWirePerformanceResponsEase™grindtechnologyDURASTEEL™corematerialPolymerCoated/HydrocoatDistalsegmentSofttipdesignedforfrontlineuse25hWHISPER™RedefinesPolymerWirHI-TORQUEPILOT™Design26hHI-TORQUEPILOT™Design26hHI-TORQUEPILOT™FamilyProductDescriptionDesignHighlights: •Polymer-tip,hydrophilic •Core-to-tipwithmoderatesupport •Graduatedtipstiffnessinthefamily •ModifiedRESPONSEASE™parabolicgrind •DURASTEEL™corematerial •Singlelesionmeasurementmarker27hHI-TORQUEPILOT™FamilyProducTheHI-TORQUEPILOT™familyofguidewiresoffersachoiceofwiresthatvaryintipstiffnesstoaddressawidevarietyoflesionmorphology.Tipcoilsbeneaththepolymerhelpfacilitatetipshaping.28hTheHI-TORQUEPILOT™familyofModifiedRESPONSEASE™ParabolicGrindThismodifiedRESPONSEASE™designprovidesadditionalsupport,excellenttorquetransmissionandin-lesiontipcontrol.29hModifiedRESPONSEASE™ParaboliTheHI-TORQUEPILOT™guidewiresmaintainedtheirtipshapebetterthancompetitivewiresafterpassingthrough

atortuouspathmodel.TheDURASTEEL™corematerialoftheHI-TORQUEPILOT™familyisstrongerthanconventionalstainlesssteelforimprovedcorestrengthandtipshaperetention.DURASTEEL™withstandsmorepullingforcethanregular304vstainlesssteel.30hTheHI-TORQUEPILOT™guidewir.007”CorewireSupportPTFE喷涂–近端黑色的PTFE袖套延伸至远端头部平的显影线圈Shinobi&ShinobiPlus.010”CorewiresupportSHINOBIPlusSHINOBIWIZDOM的核心钢丝STABILIZERPlus的核心钢丝31h.007”CorewireSupportPTFE喷涂处理CTO病变时常用的导丝Coil型导丝32h处理CTO病变时常用的导丝Coil型导丝32hACSIntermediate&Standard☺Intermediate：中软缠绕头端，core-to-tip，锥行渐变的中间轴☺Standard：标准缠绕头端，不易扭曲的推送杆33hACSIntermediate&Standard☺ACS导丝34hACS导丝34hAGuidetoACSHI-TORQUEGuideWires35hAGuidetoACSHI-TORQUEGuideCrossIT36hCrossIT36hCrossIT

100-40037hCrossIT

100-40037hCrossIT特性38hCrossIT特性38hSmoothShaftwithFluororesincoatingJointlessSpringCoilPropertyofASAHINEO’S

PTCAGUIDEWIREFamilyWiththeunibodycorewhichispreciselytapereduptotheextremeend,withoutadditionalribbon,thushighlygoodtorqueabilityisachieved.Shafthasfluororesincoating,whichprovideshighoperativityandgoodmatchingwithballooncatheter.OnePieceCoreWireJointlessspringcoilmadeoftwodifferentmetalsprovidesgoodtorqueabilityandexcellentslidepropertywithdevicesMedicalGradeSiliconeCoating39hSmoothShaftwithFluororesinJointlessSpringCoilstructureimage

ASAHIJointlessspringcoil2-coil-connectedstructure

Jointlessstructureenablesverysmoothcurvingbentofthecoil/guidewireintortuousvessel.While,2-coil-bittenconnectioncoilmaymakesquarebent.Soldering40hJointlessSpringCoilstructuSoft/SoftAG141000Radio-opacity3cmCoil30cmDiameter0.014inchLength175cmFlexibilitySupportMoreMoreLessThisisafirstchoiceguidewirewithhightorqueresponseandexcellentsteerabilitybecauseoftheuniquecoreproperty.（Tipload0.7G）Intermediate/MediumAG142000Radio-opacity3cmCoil30cmDiameter0.014inchLength175cmFlexibilitySupportMoreMoreLessThisisaguidewirewithagoodbalanceoftipflexibilityandsupportperformance.（Tipload3.0G）Standard/StandardAG143000Radio-opacity3cmCoil30cmDiameter0.014inchLength175cmFlexibilitySupportMoreMoreLessImprovedtipstiffnesswithouruniquecoretaperdesign.（Tipload6.5G）Light/LightAG145000Radio-opacity3cmCoil20cmDiameter0.014inchLength175cmASAHINEO’SPTCAGuideWireLine-upImprovedlubricityandgoodtipshapememorywithouruniquecoredesign.Excellenttorqueresponse.Thiswirehasaflexibletipandcanbeusedasafirstchoicewireforalmostallprocedures.（Tipload0.5G）SupportFlexibilityMoreMoreLess41hSoft/SoftFlexibilitySupportM（Tipload3.0G）Miracle4.5/Miraclebros4.5AG14M045Radio-opacity11cmCoil11cmDiameter0.014inchLength175cmFlexibilitySupportMoreMoreLess（Tipload4.5G）Miracle6/Miraclebros6AG14M060Radio-opacity11cmCoil11cmDiameter0.014inchLength175cmFlexibilitySupportMoreMoreLess（Tipload6.0G）Miracle12/Miraclebros12AG14M070Radio-opacity11cmCoil11cmDiameter0.014inchLength175cmFlexibilitySupportMoreMoreLow（Tipload12.0G）Miracle3/Miraclebros3AG14M050Radio-opacity11cmCoil11cmDiameter0.014inchLength175cmMiracleSeriesApplyingthestructurewhichfurtherimprovestorqueperformanceforCTOuse.Thetipparthasthestructurewhichisdifficulttobetrappedbythelesions.FlexibilitySupportMoreMoreLess42h（Tipload3.0G）Miracle4.5/MiStructureofConquestPro/Pro12

0.014”200mmRadiopaqueSpringCoil0.009”StainlessCoreWirePTFECoatingHydrophilicCoatingAGH143090ConquestPro43hStructureofConquestPro/Pro1GrandSlam/GrandSlam

AG141002Radio-opacity4cmCoil4cmDiameter0.014inchLength175cmFlexibilitySupportMoreMoreLessInspiteofitsflexibletip,thecoreisalsodesignedtoprovidestrongsupportwhenapproachingthetortuouslesions.（Tipload0.7G）MarkerWireAG141010Radio-opacity3cmCoil30cmDiameter0.014inchLength175cmFlexibilitySupportMoreMoreLessSameleveloftipstiffnessasSOFT.Ithastenmarkersstartingafter50mmfromthetiptoscalelesionsandpositiondevices.（Tipload0.7G）Rinato/ProwaterAG146000Radio-opacity3cmCoil20cmDiameter0.014inchLength175cmCONQUEST/ConfianzaAG143090Radio-opacity20cmCoil20cmDiameter0.014inchLength175cmThiswireisdevelopedforCTOuse.HigherpenetrationabilitythanMiracles.Diameteroftipcoilistaperedto0.009inch(φ0.23mm).（Tipload9.0G）FlexibilitySupportMoreMoreLessHydrophiliccoatingoverthecoilspring(after3cmfromthetip).NewlydesignedoriginalcoreshaftgivesadequatelyhighersupportperformancethanSOFT,improvedtorqueperformance.（Tipload0.8G）FlexibilitySupportMoreMoreLess44hGrandSlam/GrandSlamFlexib45h45h46h46h如何选择导丝47h如何选择导丝47h

下列情况首选超滑涂层的导丝1.闭塞段近端无边支开口，病变长度<20mm，血管残端程鼠尾状状。鼠尾状48h下列情况首选超滑涂层的导丝1.闭塞段近端无边支开口，病变下列情况首选超滑涂层的导丝2.闭塞段有弯曲的闭塞段扭曲49h下列情况首选超滑涂层的导丝2.闭塞段有弯曲的闭塞段扭曲49下列情况首选超滑涂层的导丝3.闭塞段近端及远端弯曲重的近端过度扭曲远端过度扭曲50h下列情况首选超滑涂层的导丝3.闭塞段近端及远端弯曲重的近端下列情况首选尖端缠绕形导丝1.血管残端呈齐头的2.闭塞段近端有分支开口的齐头闭塞51h下列情况首选尖端缠绕形导丝1.血管残端呈齐头的齐头闭塞51下列情况首选尖端缠绕形导丝3.闭塞段长度>20mm4.闭塞时间>6个月52h下列情况首选尖端缠绕形导丝3.闭塞段长度>20mm52h导丝通过闭塞段时的情况1.导丝通过闭塞1-6个月内、长度<20mm没有钙化的病变时较顺利，成功率高。53h导丝通过闭塞段时的情况1.导丝通过闭塞1-6个月内、长度<导丝通过闭塞段时的情况2.导丝通过有硬核的闭塞段时导丝无法穿透斑块，其尖端沿斑块边缘穿透血管壁导丝强行穿过硬斑块核54h导丝通过闭塞段时的情况2.导丝通过有硬核的闭塞段时导丝无法如何判断导丝是否在真腔1.根据不同的投照角度55h如何判断导丝是否在真腔1.根据不同的投照角度55h如何判断导丝是否在真腔2.根据导丝尖端的形态和走性真腔中导丝尖端弯形“J”存在，导丝可自由旋转，可沿主支血管走形前进，也能进入相应分支，并每次均能规律进入同一走行分支。56h如何判断导丝是否在真腔2.根据导丝尖端的形态和走性56h如何判断导丝是否在真腔3.通过侧支循环显示闭塞段远端造影通过逆行或顺行侧支显示闭塞段远端，多角度透射观察导丝是否在真腔；在导丝即将通过闭塞段进入闭塞段远端血管真腔时尤应谨慎，导丝每前进1-2mm就应多角度投照，调整导丝尖端方向，防止损伤闭塞段远端血管，造成长夹层而不可修复。57h如何判断导丝是否在真腔3.通过侧支循环显示闭塞段远端57h如何判断导丝是否在真腔4.通过OTW球囊造影判断一旦导丝在假腔，造影时造影剂冲击损伤血管内膜，形成全程长夹层，导丝无法在进真腔，并造成远端血管闭塞－－心梗。

此法很少用.58h如何判断导丝是否在真腔4.通过OTW球囊造影判断导丝成形及操作技巧59h导丝成形及操作技巧59hCTO病变导丝尖端成形半径要小成形半径大，则前向力被分解，导丝不易前行成形半径大，对血管壁损伤大成形半径大，不易调整方向60hCTO病变导丝尖端成形半径要小成形半径大，则前向力被分解，导闭塞段近端成角大的病变要先将导丝头端塑形成较大的角度，使其易于通过闭塞段近端的扭曲，并将微导管或OTW球囊导入到病变处；再将导丝重新塑形成小角度或换用塑形成小角度硬导丝，尝试通过病变。61h闭塞段近端成角大的病变要先将导丝头端塑形成较大的角度，使其易闭塞段较硬的病变对于较硬的病变估计球囊不易通过者，除在导丝头端塑形成角后，可在导丝尖端再塑形第二个小角（只适用于CrossIT300-400、ConquestPro9-12及Miracle9-12），将闭塞病变“掏”大，但导丝旋转速度不能快。62h闭塞段较硬的病变对于较硬的病变估计球囊不易通过者，除在导丝头63h63hCTO病变的支架选择64hCTO病变的支架选择64hCTO病变中PTCA和支架植入术比较：再狭窄发生率65hCTO病变中PTCA和支架植入术比较：再狭窄发生率65hCTO病变中PTCA和支架植入术比较：再闭塞发生率66hCTO病变中PTCA和支架植入术比较：再闭塞发生率66h相对于单纯PTCA术，金属裸支架降低了再狭窄和再闭塞率，但仍然比较高．与金属裸支架相比雷帕霉素药物支架明显降低了低或中危再狭窄风险病人的晚期管腔丢失和再狭窄率

67h相对于单纯PTCA术，金属裸支架降低了再狭窄和再闭塞率，但仍CTO中应用CYPHERstent的经验HoyeA.,etal.,JAmCollCardiol2004;43(11):1954-8.-56例CYPHER治疗GeL.,etal.,EurHeartJ2005:26(11):1056-62-122例CYPHER治疗NakamuraS.,etal.,AmJCardiol2005;95:161-6-60例CYPHER治疗TheSICTOStudyCYPHERTM

Sirolimus-elutingstent

in

Chronic

Total

OcclusionThePRISONII

StudyPrimaryStentingofOccludedNativeCoronaryArteries

68hCTO中应用CYPHERstent的经验HoyeA.,SICTOSTUDYDESIGNAmulticenter,prospective,non-randomizedstudytoassessthefeasibilityandrestenosis/reocclusionratesofcoronarystentingwiththeCypherTMSirolimus-elutingstentinpatientswithchronictotalocclusion25patientsweretreatedwiththeCypherTMSirolimus-elutingstentaftersuccessfulballoonangioplastyandIVUSexamination.Clinicalfollow-upat30days,6,12,18and24months-repeatangiographyandIVUSat6monthsfollow-up.69hSICTOSTUDYDESIGN25patientsSICTO

–ConclusionInthisfeasibilitystudytheCYPHERTMSirolimus-elutingstentwasveryeffectiveinthetreatmentofCTO,withverylowratesofTLR(0%),MACE(0%)andTVR(8%)

comparedtohistoricaldatawithbarestents(30-50%).TheCYPHERTMSirolimus-elutingstentsignificantlyinhibitsintimalhyperplasiainCTO.ThesepreliminarydatawillcomeinadditionoflargerdatabasewithCTOsubpopulation(e.g.e-Cypher)70hSICTO–ConclusionInthisfeas

PRISONIIStudyTocomparetheimmediateandlong-termangiographicandclinicalresultsofBMS(BxVelocity™)implantationwithSirolimus-elutingStent(CYPHER™)implantationforthetreatmentofCTO71hPRISONIIStudyTocompare6-monthClinicalFollow-upClinicalEvent(%)204P<0.001248228194320P=0.003P=0.009P=0.001P=NSP=NS072h6-monthClinicalFollow-upClin6-monthAngiographicFollow-up

In-StentBMS(n=94)SES(n=94)pvalueRef.diameter(mm)3.01±0.853.44±0.54<0.0001MLD(mm)1.47±0.832.48±0.80<0.0001%diam.stenosis48.75±26.5222.01±20.98<0.0001LateLoss(mm)1.09±0.910.05±0.81<0.0001Netgain(mm)1.30±0.882.33±0.85<0.0001Lossindex0.45±0.37-0.02±0.41<0.000173h6-monthAngiographicFollow-upP<0.0001P<0.00014136117%73%81%AngiographicBinaryRestenosis

RelativeRiskReduction74hP<0.0001P<0.00014136117%73%8ConclusionsAscomparedwithbaremetalstents,theCYPHER™sirolimus-elutingstentimplantationinCTOissuperiorwithasignificantreductioninbinaryin-segmentandin-stentrestenosisAsaconsequencethisresultedinasignificantreductionofTLRandTVRAlowrateofsub-acuteandlatestentthrombosiswasobservedinbothgroupsPRISONII75hConclusionsAscomparedwithbaThanks

Q&A76hThanksQ&A76h慢性完全闭塞病变介入技巧和器械选择北京安贞医院吕树铮教授77h慢性完全闭塞病变介入技巧和器械选择北京安贞医院1h慢性完全闭塞病变介入技巧和器械选择慢性完全闭塞病变的相关概念慢性完全闭塞病变的病理结构和特点CTO介入的导丝选择CTO病变的支架选择78h慢性完全闭塞病变介入技巧和器械选择慢性完全闭塞病变的相关概念CTO的定义闭塞时间大于3个月的病变79hCTO的定义闭塞时间大于3个月的病变3hCTO病变形成时间的判断AMI的时间症状加重的时间侧枝循环形成的多少及侧枝的直径80hCTO病变形成时间的判断AMI的时间4hCTO病变长度的判断顺行显影逆行显影双向造影81hCTO病变长度的判断顺行显影5h顺行显影82h顺行显影6h逆行显影83h逆行显影7hCTO病变的病理结构1.坏死脂核、胆固醇结晶及钙化84hCTO病变的病理结构1.坏死脂核、胆固醇结晶及钙化8hCTO病变的病理结构2.细胞外基质：胶原、钙化85hCTO病变的病理结构2.细胞外基质：胶原、钙化9hCTO病变的病理结构3.微血管86hCTO病变的病理结构3.微血管10hCTO病变的类型重度狭窄慢性闭塞轻中度狭窄慢性闭塞87hCTO病变的类型重度狭窄慢性闭塞11h重度狭窄慢性闭塞☺主要由纤维化和钙化的粥样硬化斑块组成☺短闭塞段：纤维帽位于闭塞段的两侧边缘，中间为血管壁重塑形成的组织，闭塞时间一般为3个月以上，重塑的组织中含有大量的纤维组织☺长闭塞段：常常有血栓的成分，闭塞段往往是纤维组织与血栓相间分布。这种病变导丝很难通过，成功率只有50～70%88h重度狭窄慢性闭塞☺主要由纤维化和钙化的粥样硬化斑块组成12h轻中度狭窄慢性闭塞脂核纤维组织陈旧血栓原有轻中度狭窄病变，班块破裂，未及时治疗，导致血管慢性闭塞，新的闭塞处远离原有狭窄斑块，导丝注意寻找闭塞斑块89h轻中度狭窄慢性闭塞脂核纤维组织陈旧血栓原有轻中度狭窄病变，班CTO病变的病理特点粥样斑块+钙化慢性发展融合而成90hCTO病变的病理特点粥样斑块+钙化慢性发展融合而成14hCTO病变的病理特点斑块破溃形成血栓机化而成91hCTO病变的病理特点斑块破溃形成血栓机化而成15hCTO介入的导丝选择92hCTO介入的导丝选择16h导丝的结构93h导丝的结构17h导引导丝的性能☺调节力：导丝尖端和中心钢丝结构☺柔软性：导丝的直径、尖端结构和连接段变系程度☺推送力：中心钢丝的硬度和中间变细方式☺支持力：中心钢丝的直径和材料94h导引导丝的性能☺调节力：导丝尖端和中心钢丝结构18h处理CTO病变时常用的导丝超滑导丝：如PTGraphicIntermediate、PT2、Shinobi、CrossNT、Whisper等Coil型导丝：ACSIntermediateStandard、CrossIT100-400、Miracle3-12及Conquest(Pro)9-12等95h处理CTO病变时常用的导丝超滑导丝：如PTGraphic处理CTO病变时常用导丝超滑导丝96h处理CTO病变时常用导丝超滑导丝20hSCIMEDPT297hSCIMEDPT221hThecombinationofapolymercoverandhydrophiliccoatingprovidesoutstandinglubricity.98hThecombinationofapolymercSCIMEDPTGraphicIntermediate

Uni-bodycorewithlong,smoothtaperfromsupportregiontotipHydrophilic-coated,polymersleeveandtipIntermediatewirewithslightlystiffertipCrossingperformanceofpolymertipwithvisibilityofspringtip99hSCIMEDPTGraphicIntermediateTerumoCrossNT100hTerumoCrossNT24hWHISPER™RedefinesPolymerWirePerformanceResponsEase™grindtechnologyDURASTEEL™corematerialPolymerCoated/HydrocoatDistalsegmentSofttipdesignedforfrontlineuse101hWHISPER™RedefinesPolymerWirHI-TORQUEPILOT™Design102hHI-TORQUEPILOT™Design26hHI-TORQUEPILOT™FamilyProductDescriptionDesignHighlights: •Polymer-tip,hydrophilic •Core-to-tipwithmoderatesupport •Graduatedtipstiffnessinthefamily •ModifiedRESPONSEASE™parabolicgrind •DURASTEEL™corematerial •Singlelesionmeasurementmarker103hHI-TORQUEPILOT™FamilyProducTheHI-TORQUEPILOT™familyofguidewiresoffersachoiceofwiresthatvaryintipstiffnesstoaddressawidevarietyoflesionmorphology.Tipcoilsbeneaththepolymerhelpfacilitatetipshaping.104hTheHI-TORQUEPILOT™familyofModifiedRESPONSEASE™ParabolicGrindThismodifiedRESPONSEASE™designprovidesadditionalsupport,excellenttorquetransmissionandin-lesiontipcontrol.105hModifiedRESPONSEASE™ParaboliTheHI-TORQUEPILOT™guidewiresmaintainedtheirtipshapebetterthancompetitivewiresafterpassingthrough

atortuouspathmodel.TheDURASTEEL™corematerialoftheHI-TORQUEPILOT™familyisstrongerthanconventionalstainlesssteelforimprovedcorestrengthandtipshaperetention.DURASTEEL™withstandsmorepullingforcethanregular304vstainlesssteel.106hTheHI-TORQUEPILOT™guidewir.007”CorewireSupportPTFE喷涂–近端黑色的PTFE袖套延伸至远端头部平的显影线圈Shinobi&ShinobiPlus.010”CorewiresupportSHINOBIPlusSHINOBIWIZDOM的核心钢丝STABILIZERPlus的核心钢丝107h.007”CorewireSupportPTFE喷涂处理CTO病变时常用的导丝Coil型导丝108h处理CTO病变时常用的导丝Coil型导丝32hACSIntermediate&Standard☺Intermediate：中软缠绕头端，core-to-tip，锥行渐变的中间轴☺Standard：标准缠绕头端，不易扭曲的推送杆109hACSIntermediate&Standard☺ACS导丝110hACS导丝34hAGuidetoACSHI-TORQUEGuideWires111hAGuidetoACSHI-TORQUEGuideCrossIT112hCrossIT36hCrossIT

100-400113hCrossIT

100-40037hCrossIT特性114hCrossIT特性38hSmoothShaftwithFluororesincoatingJointlessSpringCoilPropertyofASAHINEO’S

PTCAGUIDEWIREFamilyWiththeunibodycorewhichispreciselytapereduptotheextremeend,withoutadditionalribbon,thushighlygoodtorqueabilityisachieved.Shafthasfluororesincoating,whichprovideshighoperativityandgoodmatchingwithballooncatheter.OnePieceCoreWireJointlessspringcoilmadeoftwodifferentmetalsprovidesgoodtorqueabilityandexcellentslidepropertywithdevicesMedicalGradeSiliconeCoating115hSmoothShaftwithFluororesinJointlessSpringCoilstructureimage

ASAHIJointlessspringcoil2-coil-connectedstructure

Jointlessstructureenablesverysmoothcurvingbentofthecoil/guidewireintortuousvessel.While,2-coil-bittenconnectioncoilmaymakesquarebent.Soldering116hJointlessSpringCoilstructuSoft/SoftAG141000Radio-opacity3cmCoil30cmDiameter0.014inchLength175cmFlexibilitySupportMoreMoreLessThisisafirstchoiceguidewirewithhightorqueresponseandexcellentsteerabilitybecauseoftheuniquecoreproperty.（Tipload0.7G）Intermediate/MediumAG142000Radio-opacity3cmCoil30cmDiameter0.014inchLength175cmFlexibilitySupportMoreMoreLessThisisaguidewirewithagoodbalanceoftipflexibilityandsupportperformance.（Tipload3.0G）Standard/StandardAG143000Radio-opacity3cmCoil30cmDiameter0.014inchLength175cmFlexibilitySupportMoreMoreLessImprovedtipstiffnesswithouruniquecoretaperdesign.（Tipload6.5G）Light/LightAG145000Radio-opacity3cmCoil20cmDiameter0.014inchLength175cmASAHINEO’SPTCAGuideWireLine-upImprovedlubricityandgoodtipshapememorywithouruniquecoredesign.Excellenttorqueresponse.Thiswirehasaflexibletipandcanbeusedasafirstchoicewireforalmostallprocedures.（Tipload0.5G）SupportFlexibilityMoreMoreLess117hSoft/SoftFlexibilitySupportM（Tipload3.0G）Miracle4.5/Miraclebros4.5AG14M045Radio-opacity11cmCoil11cmDiameter0.014inchLength175cmFlexibilitySupportMoreMoreLess（Tipload4.5G）Miracle6/Miraclebros6AG14M060Radio-opacity11cmCoil11cmDiameter0.014inchLength175cmFlexibilitySupportMoreMoreLess（Tipload6.0G）Miracle12/Miraclebros12AG14M070Radio-opacity11cmCoil11cmDiameter0.014inchLength175cmFlexibilitySupportMoreMoreLow（Tipload12.0G）Miracle3/Miraclebros3AG14M050Radio-opacity11cmCoil11cmDiameter0.014inchLength175cmMiracleSeriesApplyingthestructurewhichfurtherimprovestorqueperformanceforCTOuse.Thetipparthasthestructurewhichisdifficulttobetrappedbythelesions.FlexibilitySupportMoreMoreLess118h（Tipload3.0G）Miracle4.5/MiStructureofConquestPro/Pro12

0.014”200mmRadiopaqueSpringCoil0.009”StainlessCoreWirePTFECoatingHydrophilicCoatingAGH143090ConquestPro119hStructureofConquestPro/Pro1GrandSlam/GrandSlam

AG141002Radio-opacity4cmCoil4cmDiameter0.014inchLength175cmFlexibilitySupportMoreMoreLessInspiteofitsflexibletip,thecoreisalsodesignedtoprovidestrongsupportwhenapproachingthetortuouslesions.（Tipload0.7G）MarkerWireAG141010Radio-opacity3cmCoil30cmDiameter0.014inchLength175cmFlexibilitySupportMoreMoreLessSameleveloftipstiffnessasSOFT.Ithastenmarkersstartingafter50mmfromthetiptoscalelesionsandpositiondevices.（Tipload0.7G）Rinato/ProwaterAG146000Radio-opacity3cmCoil20cmDiameter0.014inchLength175cmCONQUEST/ConfianzaAG143090Radio-opacity20cmCoil20cmDiameter0.014inchLength175cmThiswireisdevelopedforCTOuse.HigherpenetrationabilitythanMiracles.Diameteroftipcoilistaperedto0.009inch(φ0.23mm).（Tipload9.0G）FlexibilitySupportMoreMoreLessHydrophiliccoatingoverthecoilspring(after3cmfromthetip).NewlydesignedoriginalcoreshaftgivesadequatelyhighersupportperformancethanSOFT,improvedtorqueperformance.（Tipload0.8G）FlexibilitySupportMoreMoreLess120hGrandSlam/GrandSlamFlexib121h45h122h46h如何选择导丝123h如何选择导丝47h

下列情况首选超滑涂层的导丝1.闭塞段近端无边支开口，病变长度<20mm，血管残端程鼠尾状状。鼠尾状124h下列情况首选超滑涂层的导丝1.闭塞段近端无边支开口，病变下列情况首选超滑涂层的导丝2.闭塞段有弯曲的闭塞段扭曲125h下列情况首选超滑涂层的导丝2.闭塞段有弯曲的闭塞段扭曲49下列情况首选超滑涂层的导丝3.闭塞段近端及远端弯曲重的近端过度扭曲远端过度扭曲126h下列情况首选超滑涂层的导丝3.闭塞段近端及远端弯曲重的近端下列情况首选尖端缠绕形导丝1.血管残端呈齐头的2.闭塞段近端有分支开口的齐头闭塞127h下列情况首选尖端缠绕形导丝1.血管残端呈齐头的齐头闭塞51下列情况首选尖端缠绕形导丝3.闭塞段长度>20mm4.闭塞时间>6个月128h下列情况首选尖端缠绕形导丝3.闭塞段长度>20mm52h导丝通过闭塞段时的情况1.导丝通过闭塞1-6个月内、长度<20mm没有钙化的病变时较顺利，成功率高。129h导丝通过闭塞段时的情况1.导丝通过闭塞1-6个月内、长度<导丝通过闭塞段时的情况2.导丝通过有硬核的闭塞段时导丝无法穿透斑块，其尖端沿斑块边缘穿透血管壁导丝强行穿过硬斑块核130h导丝通过闭塞段时的情况2.导丝通过有硬核的闭塞段时导丝无法如何判断导丝是否在真腔1.根据不同的投照角度131h如何判断导丝是否在真腔1.根据不同的投照角度55h如何判断导丝是否在真腔2.根据导丝尖端的形态和走性真腔中导丝尖端弯形“J”存在，导丝可自由旋转，可沿主支血管走形前进，也能进入相应分支，并每次均能规律进入同一走行分支。132h如何判断导丝是否在真腔2.根据导丝尖端的形态和走性56h如何判断导丝是否在真腔3.通过侧支循环显示闭塞段远端造影通过逆行或顺行侧支显示闭塞段远端，多角度透射观察导丝是否在真腔；在导丝即将通过闭塞段进入闭塞段远端血管真腔时尤应谨慎，导丝每前进1-2mm就应多角度投照，调整导丝尖端方向，防止损伤闭塞段远端血管，造成长夹层而不可修复。133h如何判断导丝是否在真腔3.通过侧支循环显示闭塞段远端57h如何判断导丝是否在真腔4.通过OTW球囊造影判断一旦导丝在假腔，造影时造影剂冲击损伤血管内膜，形成全程长夹层，导丝无法在进真腔，并造成远端血管闭塞－－心梗。

此法很少用.134h如何判断导丝是否在真腔4.通过OTW球囊造影判断导丝成形及操作技巧135h导丝成形及操作技巧59hCTO病变导丝尖端成形半径要小成形半径大，则前向力被分解，导丝不易前行成形半径大，对血管壁损伤大成形半径大，不易调整方向136hCTO病变导丝尖端成形半径要小成形半径大，则前向力被分解，导闭塞段近端成角大的病变要先将导丝头端塑形成较大的角度，使其易于通过闭塞段近端的扭曲，并将微导管或OTW球囊导入到病变处；再将导丝重新塑形成小角度或换用塑形成小角度硬导丝，尝试通过病变。137h闭塞段近端成角大的病变要先将导丝头端塑形成较大的角度，使其易闭塞段较硬的病变对于较硬的病变估计球囊不易通过者，除在导丝头端塑形成角后，可在导丝尖端再塑形第二个小角（只适用于CrossIT300-400、ConquestPro9-12及Miracle9-12），将闭塞病变“掏”大，但导丝旋转速度不能快。138h闭塞段较硬的病变对于较硬的病变估计球囊不易通过者，除在导丝头139h63hCTO病变的支架选择140hCTO病变的支架选择64hCTO病变中PTCA和支架植入术比较：再狭窄发生率141hCTO病变中PTCA和支架植入术比较：再狭窄发生率65hCTO病变中PTCA和支架植入术比较：再闭塞发生率142hCTO病变中PTCA和支架植入术比较：再闭塞发生率66h相对于单纯PTCA术，金属裸支架降低了再狭窄和再闭塞率，但仍然比较高．与金属裸支架相比雷帕霉素药物支架明显降低了低或中危再狭窄风险病人的晚期管腔丢失和再狭窄率

143h相对于单纯PTCA术，金属裸支架降低了再狭窄和再闭塞率，但仍CTO中应用CYPHERstent的经验HoyeA.,etal.,JAmCollCardiol2004;43(11):1954-8.-56例CYPHER治疗GeL.,etal.,EurHeartJ2005:26(11):1056-62-122例CYPHER治疗NakamuraS.,etal.,AmJCardiol2005;95:161-6-60例CYPHER治疗TheSICTOSt