钙化病变介入治疗难点与挑战

CalcifiedCoronaryLesion:

DifficultiesandChallenges

Sweetdreamornightmare？MarkerforCADandincreasedmortality

JACC:CARDIOVASCULARIMAGING.2010DecJACC:CARDIOVASCULARIMAGING.2012Oct4,425SuspectedCADpatientsFollow-up3years

4,609asymptomaticindividualsFollow-up3.1yearsMulti-EthnicStudyCAC>1000

increasedriskofanginacomparedtoCAC400-999Coylewrightetal.Atherosclerosis.2011

CalcifiedCoronaryLesion——NightmareofPCI6296patients,sevenclinicaldrug-elutingstentstrials3-yearsfollow-upSeverecoronarycalcificationlesscompleterevascularisation(48%vs55.6%,p<0.001)increasedmortality(10.8%vs4.4%,p<0.001)highend-pointdeath—MI(23.2%vs10.9%;p<0.001)highdeath—MI—anyrevascularisation(31.8%vs22.4%;p<0.001)Conclusions:CCLappearsasanindependentpredictorofworseprognosisChristosVBourantasetal.Heart.

2014;Sep

CalcifiedCoronaryLesioninOurstudy

616patientswithSAPandnormalTNI

CoronarycalciumwasdeterminedbyCTAbeforePCISeverecoronarycalcificationHighoccurrenceofPMIanddissectionrate

ZhouYJetal.PLoSOne2013Dec

17;8(12)Stentthrombosis6RiskFactors（TheMESAstudy）RaceandgenderAgeBMISmokingFamilyhistoryofheartattackHyperlipidemiaIntimalcalcificationHypertensionIntimalcalcificationDiabetesMedialcalcificationCKDMedialcalcificationRheumaticdiseasesCalciumintake？Circulation.2007;115:2722-2730Calciumintake＆vascularcalcification

（Systematicreviewsandmeta-analyses）ThemajorityofthestudiesdemonstratedCalciumintakehadnosignificantadverseorbeneficialeffectonvascularcalcificationandcardiovascularendpointsDietarycalciumintakeabovethemedianof805mg/dwasassociatedwithanincreasedriskofMIItwouldbeunwisetoceasingconsumptionofcalciumsupplementsatrecommendedlevelswhenadequatedietarycalciumcannotbeachieve

SpenceLA.NutrRev.2013Jan;71(1):15-22RaffieldLMetal.AmJClinNutr2014Oct;100(4)Calciumintake＆vascularcalcification

(Cross-sectionalanalysisin720individualswithtype2diabetes)NosignificantassociationsofcalciumfromdietorsupplementswithcalcifiedplaqueNogreatermortalityriskwasobservedwithincreasedcalciumintakeInstead,calciumsupplementusewasmodestlyassociatedwithreducedall-causemortalityinwomen

(P=0.017)InverserelationshipbetweenBMIandCACAtherosclerosis.2012March;221(1):176–182.9,993patientsundergoingPCICalcificationbasedonangiographyConclusionsInversecorrelationbetweenBMIandindexlesioncalcificationMechanismofCACVascularcalcificationisanactive,regulatedprocessBMP-WntsignalingBMP-Smad

signalingMajorTheoriesofVascularCalcificationVascularcalcificationApoptoticbodiesCELLDEATHLOSSOFINHIBITIONPyrophosphateMGPOPNFetuin/alpha2-HSglycoproteinOthersMatrixVesiclesDISTURBEDCa/PiBALANCEHyperphosphatemiaHypercalcemiaINDUCTIONOFBONEFORMATIONVascularboneandcartilage-likecellsINDUCINGFACTORSPiLipidsInflammatorycytokinesOthersBisphosphonatesOPGBoneRemodelingCIRCULATINGNUCLEATIONALCOMPLEXESCaxPiDISTURBEDCa/PiBALANCEHyperphosphatemiaHypercalcemiaINDUCINGFACTORSPiLipidsInflammatorycytokinesOthersApoptoticbodiesMatrixVesiclesINDUCTIONOFBONEFORMATIONVascularboneandcartilage-likecellsDISTURBEDCa/PiBALANCEHyperphosphatemiaHypercalcemiaINDUCINGFACTORSPiLipidsInflammatorycytokinesOthersCELLDEATHBisphosphonatesOPGApoptoticbodiesMatrixVesiclesINDUCTIONOFBONEFORMATIONVascularboneandcartilage-likecellsDISTURBEDCa/PiBALANCEHyperphosphatemiaHypercalcemiaINDUCINGFACTORSPiLipidsInflammatorycytokinesOthersCIRCULATINGNUCLEATIONALCOMPLEXESCELLDEATHBisphosphonatesOPGApoptoticbodiesMatrixVesiclesINDUCTIONOFBONEFORMATIONVascularboneandcartilage-likecellsDISTURBEDCa/PiBALANCEHyperphosphatemiaHypercalcemiaINDUCINGFACTORSPiLipidsInflammatorycytokinesOthersBoneRemodelingCIRCULATINGNUCLEATIONALCOMPLEXESCELLDEATHBisphosphonatesOPGApoptoticbodiesMatrixVesiclesINDUCTIONOFBONEFORMATIONVascularboneandcartilage-likecellsDISTURBEDCa/PiBALANCEHyperphosphatemiaHypercalcemiaINDUCINGFACTORSPiLipidsInflammatorycytokinesOthersNoeffectivemedicinetreatmentEvidencefrommeta-analysesStatinandLDL-CStatinandcalcificationCoylewrightetal.Atherosclerosis.2011StatinspromoteCAC(VADTtrail)

Saremietal.DiabetesCare.2012;2390-2StrategyofPCIinCACBalloonangioplastyCuttingballoonRotablatorStentPostdilationLaserDiagnosisandTreatmentofCoronaryArteryCalcification

（2014Chinaexpertconsensus）ChinJInterventCardiol,February2014CAG

Sensitivity48%Specificity89%(98%inseverecalcifiedlesions)IVUS

GoldenStandardClassⅠ0°—90°calcificationClassⅡ91°—180°calcificationClassⅢ181°—270°calcificationClassⅣ>270°calcificationDiagnosisofCoronaryArteryCalcification

（2014Chinaexpertconsensus）ChinJInterventcardiol.2014Feb(22)69-73StrategyforballoonangioplastySmallsizeballoonpreferedPressureofBCfrom8atm,slowlyincreaseTheuplimitofpressuremaybe16atmforregularballoon,buthigherpressurefornoncompliantballoonFlowrestrictingdissectionorperforationbeconcernedTexHeartInstJ2012;39(5):635-8High-PressureDilationwithaNewNoncompliantBalloonSevereproximalandmid-segmentLADlesions(Fig.1A)2drug-elutingEndeavorResolutestents2.75×24-mmdistally,3×24-mmproximally(Fig.1B-C)Postdilate:30atm3.5×12-mmSprinterNCballoon(Fig.1D)Postdilate:40atm3×15-mmOPNNCballoon(Fig.1E)CuttingballoonforcalcifiedlesionIndicationforcuttingballoon:Lesionrelativelyshort(<20mm)ConcentriclesionsHeavilycalcifiedlesionnotappropriate,butsometimesbroughtsuppriseRotablatorforcalcifiedlesionEffectivedeviceforcalcifiedlesionDifferentialtissuecutting----selectivelyhardlesion,nosofttissueOptimalburrsize---60%-70%ofreferencevesseldiameterPreventnoflow&slowflow----nitroprusside,adenosine,etcUpperlimitofrotablator:justenoughforrevascularizationRotationalAtherectomy(RA)

JACCCardiovascInterv2013Jan;6(1):10-9Randomized

ROTAXUSTrialOutcomeRandomizedROTAXUSTrialOutcome

DeathMITVRJACCCardiovascInterv2013JanUsingRAdidnotreducelatelumenlossofDESat9monthsAt9months,MACE(24.2%vs.28.3%,p=0.46),MI(6.7%vs.5.8%,p=0.79),TVR(16.7%vs.18.3%,p=0.73)weresimilarinbothgroups

Strategysuccesswassignificantlyhigherintherotablationgroup(92.5%vs.83.3%,p=0.03)RAremainsthedefaultstrategyforcomplexcalcifiedlesionsAnalysisoftheUKDatabaseMethod221,669PCIprocedures2152patients(0.97%):RA(RA+)ConclusionsRAwasundertakeninpatientswithhigherpre-proceduralrisk(older,higherincidenceofdiabetes,hypertension,PVD)Mediumtermsurvivalwasworseamongpatientsundergoing

RAProceduralsuccess(90.3%),complicationrates(9.7%)seemacceptable.RAremainsclinicallyusefulforpatientswithcalcified

coronary

lesionsIntJCardiol.2014Jan1;170(3):381-7RA

forLM

inoctogenarians42patients≥80yearsstentingforcalcifiedLMCAdiseaseProceduralsuccess

isgood(92.3%).Nodifferencewasdetectedinoverallin-hospitalorlong-termmortalityorMACCERA

appearedtobeasafeandeffectivestrategyforthetreatmentofLMCAdiseaseinoctogenarianswhowererefusedforsurgeryIntJCardiol2013Apr;26(2):173-82Rotablatorforfailedangioplasty

An84yearmanPreviousfailedangioplastyduetoballoonruptureCAGshowingsevereCCL26PCIforLAD-RotablatorStentdeployment28RotationalAtherectomyandIVUSabPrePostRA1.75mmburrPost1.75mmburrRAPreDESforcalcifiedlesionDESusewasassociatedwithasignificantlylowerriskinrepeatrevascularizationcomparedtoBMSgroupinCCL

TAXUS-IVsubstudy:9-monthangiographicfollow-up,DESsignificantlyreducedtheamountoflatelosscomparedwiththeBMS(0.26+/-0.56vs0.51+/-0.48mm,p=0.015)inthecalcificlesionsSripalBangalore,CatheterCardiovascInterv.2011JanMoussaI,AmJCardiol.2005NovThin-StrutDESaremorefavorableforSevereCalcifiedLesionsafterRotationalAtherectomythanThick-StrutDES

YasuharuLee,JINVASIVECARDIOL,2014FebDESforcalcifiedlesionPostdilationforcalifiedlesionPostdialationlaststrawforcalifiedlesionNoncompliant,highpressureballoonfirstchoiceBecarefulcoronaryperforationorseriousdissectionPostdilationinsevereCCL33Clinicalpresentation3Diagnosis:UAPPriorMIHypertension

1Progressivedeteriorationofchestpainfor3years(CCSII),presentedwithunstableepisodesinlast2weeks(CCSIII)2WithahistoryofHBP,priorinferiorandanteriormyocardialinfarctionMale,84-year-oldTnIlevelsof0.01ng/mL(normalrange,<0.05ng/mL),Cre76umol/L,ALT23U/L,AST34U/LA2-dimensionalechocardiogramdemonstrateddecreasedleftventricularfunction,withanejectionfractionof41%LaboratorytestsElectrocardiogramCoronaryAngiographyCoronaryAngiographyThepatientrefusedthesurgicalsolutionandmedicalconservativetherapyAfterdiscussionthedecisionwasmadetoperformsequentialPCI:RCACTOfirst,thenunprotectedLMlesionsTreatmentstrategy

PCIforRCAGC:JR4.0,GW:Pilot50PredilationBC:Sprinter1.5x15mmand2.0x20mmFirebird22.75x33mmford-RCAandPartner3.0x36mmforp-RCA

PCIforLM1weeklaterGC:EBU3.