复杂冠脉分叉病变的PCI治疗策略

复杂冠脉分叉病变的PCI治疗策略第1页/共60页Oneortwostents?第2页/共60页NordicBifurcationStudy(n=413)413ptswithbifurcationlesion

Stentingofthemainvesselandside

branch(MV+SB)Stentingofthemainvesselandoptionalstentingofthesidebranch(MV)n=206n=207RandomizedPrimaryEndpoint:Majoradversecardiacevent(MACE)at6months第3页/共60页PrimaryEndpointofMACEat6months(%)p=NSPresentedatACC2006Therewasnodifferenceinmajoradversecardiaceventsat6months(17.7%vs12.7%;p=NS)NordicBifurcationStudy(n=413)第4页/共60页ProcedurerelatedMIwasdefinedasafive-foldelevationofbiochemicalmarkersProcedurerelatedMIoccurredmorethanthreetimesasoftenintheMV+SBgroup(13%vs4%;p=0.008)ProcedureRelatedMyocardialInfarction(%)p=0.008PresentedatACC2006NordicBifurcationStudy(n=413)第5页/共60页

OneStentStrategyProvisionalTStenting第6页/共60页ProvisionalTStent第7页/共60页Provision-Tstenttechnique53pts,SB>2mmMACE9.4%at14+/-3monthsTLR

3.8%,

MVrestensosis3.2%,

SB

12.9%at6monthsVignaC,etal.JInvasiveCardiol.2007Mar;19(3):92-7.

第8页/共60页TheSBhasanarrowingatitsostiumTheMBhasseverestenosiswithalargeplaqueburdenandtheSBoriginateswithanangleof45°TheostiumoftheSBdeterioratesafterpre-dilatationoftheMBAwireisneededinthefollowingcircumstances:ProvisionalTStent第9页/共60页FKBisVeryImportantforProvisionalTStentProvisionalTStent第10页/共60页TwoStentsTechniquesTstentCulotteSKSVstentProvisionalTModifiedTstentYstentBMSEraDESEraCrushReverseCrushBalloonCrushDKCrushMini-CrushInvertedCrush第11页/共60页TstentTechnique第12页/共60页CulotteTechnique第13页/共60页ClinicalOutcomesInBMSera,theincidenceofTLRwas24%at6months(Chevalier.AmJCardiol1998;82:943)InDESera,theincidenceofMACEwas5.3%andTLRwas15.4%(Hoye,etal.IntJCardiovascinterven2005;7:36)第14页/共60页CulottevsTstentinDESera

80patientswithbifurcationlesions

Culottetechnique

45casesTstent35casesTheproceduralsuccessrate100%TLR:8.9%P=0.014;9monthsMACE13.3%P=0.051KaplanS,etal.AmHeartJ.2007Aug;154(2):336-43

Theproceduralsuccessrate100%TLR:27.3%9monthsMACE27.3%第15页/共60页SKSTechnique第16页/共60页ClinicalOutcome200patientswithbifurcationlesions

SKStechnique

CypherstentsTheclinicalsuccessrateis97%TheincidenceofTLR:4%9+/-2monthsSharmaSK.CatheterizationandCardiovascularInterventions2005;65:10第17页/共60页ClinicalOutcome36patientswithbifurcationlesions

SKStechnique

SESstents26.7+/-8.6monthTheproceduresuccessrateis100%NoMACE,MBrestenosis13%,SB10%TheincidenceofTLR:14%,KimYH,etal.CatheterCardiovascInterv.2007Nov15;70(6):840-6

第18页/共60页YStentTechnique第19页/共60页CrushTechnique第20页/共60页ClinicalOutcomesThesurvivalratefreeofTLRwas90.3%,incidenceofrestenosisatMBwas9.1%,restenosisatSBwas25.3%(HoyeA.JAmCollCardiol2006;47:1949-1958)IncidenceofTLRat6monthfollow-upis11.3%(MoussaIAmJCardiol2006；97：1317－1321)第21页/共60页Colomboetal.PCR2004FinalKissingisveryimportant!第22页/共60页Step1:WirebothbranchesandpredilatebothStep2:Bothstentsinplace.Side-branchstentpositionedmoreproximalInvertedCrush

第23页/共60页WirebothbranchesandpredilateDeploystentinmainbranchReversecrushingtechnique第24页/共60页WiresidebranchanddilatePositionstentinsidebranchprotrudinginMB(slight),leaveaballooninMB第25页/共60页DeploystentinthesidebranchandremovewireandballoonCrushtheprotrudingpartofSBontopofthestentinMB第26页/共60页BalloonCrush第27页/共60页DKCrush(SleeveTechnique)第28页/共60页mini-crush45pts,52lesionsProceduralsuccess100%Noin-hospitalMACETLR12.2%,

MVrestensosis12.2%,

SB

2%at8monthsGalassiAR,etal.CatheterCardiovascInterv.20071;69(7):976-83第29页/共60页TAPtechniqueWirebothbranchesandpredilateDeploystentinmainbranch第30页/共60页WiresidebranchanddilateKissingballoon第31页/共60页SBstentpositioningSBstentisdeployedwiththeuninflatedballoonintotheMV第32页/共60页TheballoonoftheSBstentisslightlyretrievedandalignedtotheMVballoonFinalkissingballoon第33页/共60页InvitroTAPstentingPerfectcoverageofthebifurcationwithminimalstent’sstrutsoverlapattheproximalpartofSBostium第34页/共60页0.070”0.071’’0.078”6F7F≤5.3F5.4F～5.9FTipsandtricksSizeofGuidingCatheter

MVballoonshaftprofile+SBstentshaftprofile

8F≥6.0F0.088”6F7F8FGC第35页/共60页

球囊种类（≤3.5mm)推送杆外径Maverick22.0FRyujin2.5FSeQuent2.5FAvita2.55FSprinter2.6FCrosssail2.6FKingou2.6FAquaT32.7FPowersail2.9FAVIONExtensorVoyagerGripCTO2.8F3.05.4F﹥0.070″﹥5.3F6F导管完成对吻扩张6F导引导管的内径：0.070〞0.071)两球囊推送杆外径之和应≤5.3F6F导引导管进行球囊对吻技术第36页/共60页球囊外径：2.9F+2.6F=5.5F

6F导管内径：0.070inch﹤5.4F选用导引导管：6FJL3.5第37页/共60页第38页/共60页CaseofTAPstenting第39页/共60页CoronaryAngiography第40页/共60页6FEBU3.5BMW

BMW

3.0×24mmCypher第41页/共60页DeploymentMVstentwithjailedguidewireintotheSBKissingballoonafterrewiringofSB第42页/共60页SBstentpositioningSBstentMVballoonThepositionoftheSBstentisadjustedtofullycovertheproximalpartoftheSBostium(redarrow)whileanuninflatedballoonkeptintotheMV第43页/共60页SBisdeployedwiththeuninflatedballoonintoMVSBstentdeployment第44页/共60页FinalkissingballoonTheballoonoftheSBstentisslightlyretrievedandalignedtotheMVballoonFinalkissingballoonSBstent’sballoon

＋MVballoon第45页/共60页FinalResult第46页/共60页ClinicalstudyofTAPBurzottaF,etal.CatheterizationandCardiovascularInterventions2007,70:75–82第47页/共60页AngiographiccharacteristicsTargetlesion

n=61

Distal

LM26

LAD/diagonal28

LCX/OM5

RCA/descendingposterior2Angulationbetweenmainandside-branch

Angle﹤70°36

Angle﹥70°26

第48页/共60页Approach

Transradial24

Transfemoral37Guidingcathetersize6Fr27Fr258Fr34Proceduretime

112±52minProcedurecharacteristics第49页/共60页Clinicaloutcome(9month)MACE4(6.6%)Death1(1.6%)Myocardialinfarction0TLR3(4.9%)StentthrombosisDefinited1(1.6%)Suspected1(1.6%)PatientswithoutMACE56(91.8%)第50页/共60页

StrategiesforLMCAlesions第51页/共60页Stentimplantationinthesidebranch?NoYes6FGuidingCa