嚴(yán)重鈣化病變的pci治療_-課件

1、Application of Percutaneous Coronary Intervention for Severe Calcification Lesions 嚴(yán)重鈣化病變的PCI治療王海昌第四軍醫(yī)大學(xué)西京醫(yī)院心臟內(nèi)科 陜西西安Culprit and Healed Plaques in a Coronary BifurcationCoronary artery disease : Diffuse disease with a variable mix of stable , vunerable and culprit plaques Fuster V, etal. JACC, 2019:

2、46:937-954Epidemiology 由動(dòng)脈粥樣硬化導(dǎo)致，非退行性變檢出率存在顯著的性別差異 （女：男=1：2）冠狀動(dòng)脈鈣化計(jì)分隨年齡增加呈增加趨勢(shì) 冠心病危險(xiǎn)因素與冠狀動(dòng)脈鈣化密切相關(guān) Bakdash 等報(bào)告非脂質(zhì)性冠狀動(dòng)脈危險(xiǎn)因素的數(shù)目與冠狀動(dòng)脈鈣化沉積有關(guān) 29% of men and 15% of women who had no cardiovascular symptoms and exhibited no other common risk factors, had extensive coronary artery calcification. European Hea

3、rt Journal 25: 4855, 2019 Angiogram cannot detect calcifications (CAG) Ultrafast computed tomography (CT scanning) can measure arterial calcification (noninvasive) Intravascular Ultrasound （IVUS） Optical Coherence Tomography (OCT)Diagnosis Methods Calcified coronary plaques imaged in vivo by optical

4、 coherence tomography (OCT) and intravascular ultrasound (IVUS)OCTOCTIVUSIVUSNon-invasive Quantification for Calcified Lesions by CT Scan“中重度鈣化（B型）病變是導(dǎo)致冠狀動(dòng)脈球囊成形術(shù)（PTCA）手術(shù)失敗和血管急性閉塞的主要危險(xiǎn)因素” 1988年ACC/AHA心血管診治技術(shù)評(píng)價(jià)的報(bào)告鈣化病變介入治療 單純球囊擴(kuò)張（PTCA） 成功率低（74），夾層率高，急性血管閉塞率高 球囊擴(kuò)張支架術(shù) 可改善球囊擴(kuò)張后的效果，提高成功率 嚴(yán)重鈣化病變，單憑高壓力植入支架，并

5、發(fā)癥高、 再狹窄率高鈣化病變單純PTCA的局限性 即刻效果 病變不能擴(kuò)展和發(fā)生彈性回縮 再狹窄 多數(shù)研究沒(méi)有顯示鈣化病變和PTCA后再狹窄之間的 關(guān)系Case 1 ( Balloon + DES)CAGCase 1 ( Balloon + DES)COSTLY! 3.5 hrs Operation time Long X-Ray Exposure 6 Balloons 3 Guide Wire 3 Drug Elution StentsCase 1 ( Balloon + DES)Pre-O Final CAG球囊成形術(shù)（PTCA） 冠脈夾層發(fā)生率高，程度重。部位在鈣化與非鈣化斑塊的移行處，與

6、球囊擴(kuò)張過(guò)程中所產(chǎn)生的不均勻的剪切力有關(guān)發(fā)生率從旋磨后的22增加到輔以球囊擴(kuò)張后的77，夾層分離的部位也從鈣化斑塊的內(nèi)（旋磨后）移至鈣化斑塊的外（PTCA后）高壓擴(kuò)張，增加了球囊破裂和夾層分離的危險(xiǎn)。Initial Reaction :Fear Atherectomy remove the plaque itself, cutting the soft plaque from the obstruction site depositing it in a capsule which is then withdrawn.Atherocathcourtesy GuidantLaserSome ca

7、theters have also been fitted with special lasers which can photo-dissolve the tissue obstructing the arteries.Laser catheter準(zhǔn)分子激光冠脈成形術(shù)（ELCA）有報(bào)道稱(chēng)手術(shù)成功率較高。使鈣化破裂而不是清除，對(duì)一些不能擴(kuò)張的病變是有效的。術(shù)后再狹窄率較高為4050。已經(jīng)被旋磨取代Rotablator : rotational atherectomy catheterRotablatorolive-shaped diamond burrrotates at extremely

8、high speedRotablator Syetem 驅(qū)動(dòng)桿導(dǎo)絲鉆石涂層磨頭1.25 mm - 2.5 mm(0.25 mm increments) 鞘管 4.3 french O.D.Rotablation is recommended for fibrotic or heavily calcified lesions that can be wired but not crossed by a balloon or adequately dilated before planned stenting. One must know how to manage the complicatio

9、ns inherent to rotablation. AHA/ACC/FDA PCI Guideline鈣化病變的分類(lèi) 內(nèi)膜面鈣化 嚴(yán)重者影響球囊、支架的充分?jǐn)U張，需要旋磨 外膜或斑塊基底部鈣化 造影顯示明顯，對(duì)PCI影響不大，不需旋磨DES時(shí)代鈣化病變治療的要點(diǎn) 鈣化病變預(yù)擴(kuò)張 支架完全覆蓋病變 支架釋放壓16-18ATM 后擴(kuò)張 血管內(nèi)超聲 STRTAS ( Study To Determine Rotablator and Transluminal Angioplasty Strategy ) 初步結(jié)果顯示，采用更大的磨頭和較長(zhǎng)的旋磨時(shí)間進(jìn)行強(qiáng)烈的消蝕與更保守的消蝕方法相比，并沒(méi)有改善

10、即刻和遠(yuǎn)期效果。 旋磨支架（rotastent）能得到最大的管腔和最小的殘余狹窄。鈣化病變介入治療的難點(diǎn)（I） 單純依靠冠脈造影評(píng)價(jià)鈣化程度欠準(zhǔn)確 植入支架后的再狹窄率高 旋磨術(shù)適于內(nèi)膜彌漫鈣化病變，利于支架充分 植入，長(zhǎng)期療效更好，“無(wú)復(fù)流現(xiàn)象”增加 斑塊切除術(shù)（DCA、TEC、ELCA）對(duì)鈣化病變幫助較小鈣化病變介入治療的難點(diǎn)（II） 直接支架植入應(yīng)當(dāng)慎重 支架通過(guò)困難，易造成支架脫落率增加 如用高壓力（16atm）仍未使支架充分?jǐn)U張者， 采用更高壓力（ 20atm ），仍可能不會(huì)達(dá)到滿(mǎn)意 的支架擴(kuò)張 支架不能充分?jǐn)U張，亞急性血栓發(fā)生率增加 內(nèi)膜夾層、撕裂率增加 球囊破裂、血管破裂、心包填

11、塞增加Case2：Severe Calcification and Balloon Suboptimal Dilation lead to Acute Stent ThrombosisMale ，57yrsSmoking 30yrs，Chest pain 3yrs，Rest ECG：V1-V3 lead ST segment depression0.1mvCadiac Triponin T(-)Severe Calcification Baloon dilation Stenting Case2：Severe Calcification and Baloon Suboptimal Dilati

12、on lead to Acute Stent Thrombosis4 days later!Female，76yrsExertional chest pain 8yrs, recurrent 10daysEF:40% RCA1:50，RCA3:75 LAD6：75,7段90 with severe calcification， 8:50，9:50；LCX13:100,14:25%,15: 50Case3： Rotational Atherectomy for Severe Calcification Cutting Balloon: 2.5*10 (16ATM, 20)Post dilate

13、balloon: 2.513 (18ATM, 12)Case3： Rotational Atherectomy for Severe Calcification Guiding ： 6F EBU3.5Guide Wire： Stablizer/ PT2MSBur: 1.5mmRotor rate ： 160000 rpmCase3： Rotational Atherectomy for Severe Calcification 2.524 TAXUS(10ATM, 8)2.7528 TAXUS(12ATM, 7)Final CAG Stenting 鈣化病變的器械選擇（I） 導(dǎo)引導(dǎo)管： 強(qiáng)支撐

14、力 導(dǎo)引導(dǎo)絲：親水涂層導(dǎo)絲， 支撐力 好， 采用微導(dǎo)管交換鋼絲 球囊和支架通過(guò)性好 鈣化病變的器械選擇（II） 支架建議選擇設(shè)計(jì)有橋連接的支架 設(shè)計(jì)良好的管狀支架，閉環(huán)系統(tǒng)、輻射力好、金屬覆 蓋率好。能夠使支架更合理擴(kuò)張、血栓率低、再狹窄 率低旋磨頭 依據(jù)血管直徑，從小到大更換，最大旋磨頭應(yīng) 選擇直徑小于血管直徑的75。鈣化病變的操作要點(diǎn)（I） 預(yù)擴(kuò)張：非常重要！ 支架往往不能直接通過(guò)病變；支架直接植入常會(huì) 導(dǎo)致支架不能充分?jǐn)U張 球囊擴(kuò)張 選擇比血管直徑小0.5mm以上的半順應(yīng)性、耐高壓 球囊，擴(kuò)張壓在8atm以上，逐漸增加壓力，直至 球囊切跡消失切割球囊的使用 小樣本研究顯示，明顯鈣化病變的

15、切割球囊治療安 全有效132 patients at least one moderate-severely calcified lesion on fluoroscopyRotablation/DES vs DES alonePrimary endpoint 8 month binary angiographic restenosisSecondary endpoints procedural success/MACE; acute/subacute/late stent thrombosisROCCSTAR Trial (Randomisation Of Calcified Coronar

16、y Stenoses to TAxus stenting with or without Rotational atherectomy)Observations to date re impact of Rotablation on procedural outcome in calcified lesionsIn arriving at 56 pts in DES alone limb, of 64 pts intended for this limb, 8 (12.5%) unable to predilate fully (placed in ROCCSTAR Rotablator registry)Subacute stent thrombosis 2/56 (3.6%) in DES alone limb (both in small vessels) vs 0/57 in Roto/DES limbRotational atherectomy expands the potential for safe and effective percutaneous treatment The device is indicat