分叉病變介入治療我的

分叉病變介入治療天津市第三中心醫(yī)院心臟中心劉迎午1整理課件pptContentDefinitionofbifurcationlesionClassificationofbifurcationlesionStrategyofbifurcation---onestentortwostentsSpecificstentforbifurcationClinicalcases2整理課件pptdefinition累及到冠狀動脈分叉的病變冠狀動脈病變中分叉病變較為常見，約占經(jīng)皮冠狀動脈介入治療(pereutaneouscoronaryintervention，PCI)的15％~20％分叉病變的解剖結(jié)構(斑塊負荷、斑塊位置、血管角度、血管直徑、分叉位置)千變?nèi)f化．而治療過程中解剖結(jié)構也會隨時改變(斑塊遷移、血管夾層)所以無兩個完全一致的分叉病變，更無一種可適用于所有分叉病變的手術方法3整理課件pptClassification4整理課件pptClassificationofbifurcationlesionsaccordingtoplaqueburdenA:DukeB:SanbornC:SafianD:Lefevre5整理課件pptMedinaA.etal.RevEspCardiol.2006;59:183-4ANewClassificationofCoronaryBifurcationLesions-MedinaClassification1,1,11,1,01,0,10,1,11,0,00,1,00,0,1MBDistalMBProximalSB6整理課件ppt一個好還是兩個好？如果選２個，應該采取何種策略?策略選擇的根據(jù)簡單化vs復雜化循證結(jié)果vs個人選擇并發(fā)癥率(especiallyMI/thrombosis)分叉病變介入治療

-關注熱點7整理課件pptStentingforbifurcationlesionsin2007主支放支架，分支臨時決定Stentingthemainvesselwithprovisionalstentingofthesidebranch8整理課件pptProvisionalStentingStrategy

If2ndstentisneededforsidebranchfollowingmainvesselstentingModifiedT-stentingReversecrushing Culottestenting 9整理課件ppt分支血管的保護與放置支架

并非所有分支血管同等重要!

根據(jù)以下情況實施分支血管保護和支架植入分支血管大小與分布區(qū)域分支血管開口病變與病變程度分支與主支成角程度10整理課件pptSidebranchclosureafterPCI11整理課件pptSide-branchmaybecompromisedfollowingmainvesselstentingPre-treatmentAfterstentingPlaqueshifting(“Snow-plow”)OstialspasmorSide-branchcompromisebystentmaterialDissectionofplaqueatoriginofside-branchDissectionflapatmainarteryobstructingoriginofside-branchAttimes,thesidebranchcouldbecompromisedbythrombustoo12整理課件pptDifferenttechniquesoftwostentsbyintentiontotreatbifurcationlesionsTheVstentingtechniqueThesimultaneouskissingstentstechniqueTheTstentingandmodifiedTstentingtechniqueThecrushtechnique(Thereversecrushtechnique/Thestepcrushtechnique/Theinvertedcrushtechnique)TheculottesstentingtechniqueTheYstentingtechniqueTheskirttechnique13整理課件pptTheVstentingtechnique14整理課件pptThesimultaneouskissingstentstechnique15整理課件pptTheVstentingandthesimultaneouskissingstentingtechnique適合于分叉病變位于接近開口的血管近端，例如位于左主干的分叉病變，并且左主干短或無病變。理想夾角<90°。V支架也適合于其他部位的分叉病變，近段無病變或無須支架。16整理課件pptTheVstentingandthesimultaneouskissingstentingtechnique優(yōu)點:保證不會丟失分支。

對吻技術時無須re-crossanystent.17整理課件pptTheVstentingandthesimultaneouskissingstentingtechnique缺點:雙支架近端定位較困難；不可避免造成其中一個支架偏心，往往引起agap。18整理課件pptTheTstentingtechnique19整理課件pptThemodifiedTstentingtechnique20整理課件pptTheTandmodifiedTstentingtechnique優(yōu)點:較crush技術容易完成。缺點:大多數(shù)情況下，分支開口不能完全覆蓋。21整理課件pptColomboetalCirculation2004;109:1244-1249*Highcross-overratefromStent+BalloontoStent+Stentgroup(22/43,51%)CypherBifurcationStenting(T-stenting)EffectsoftheTstentingtechnique22整理課件pptRESEARCHbifurcationsubgroupRRofdifferenttechniquesThehighrestenosisrateofTstentingtechniquemayberelatedtotheincompletecoverageofstentingbeinglocatedattheostiumofSB.TanabeK,HoyeA,LemosPA,etal.AmJCardiol,2004,91:115-8EffectsoftheTstentingtechnique23整理課件pptVstentingvsTstentingSharmaetal.Vstenting:100ProvisionalTstenting:10032%subjectsreceivedCypherstentandRVDwas3.32mm。24整理課件pptProvisionalTstenting25整理課件ppt優(yōu)點:HigherproceduralsuccessrateLowerexpenseLowercomplicationsLowerre-PCI7monsTLR<15%。Lefevreetal:ProvisionalTstentingisthegoldenstandardtotreatfalsebifurcationlesion(tpye2,3and4a),mostsubjectsonlyneedonestentimplantation。ProvisionalTstenting26整理課件pptThecrushtechnique27整理課件pptThecrushtechnique優(yōu)點:可以保證兩條分支的立刻開通,這點對保護功能上重要的分支非常重要?？梢酝耆采w分支開口。缺點:由于有多層支架金屬，導絲和球囊再次通過較困難，操作復雜。28整理課件pptGeetal.JACC2005;46:613Longtermoutcomeof“Crush”Stentingtechnique29整理課件ppt6monsRRColomboetal.Thecrushtechnique30整理課件pptThereversecrushorinternalcrushtechnique31整理課件pptThereversecrushorinternalcrushtechnique主要用于臨時分支支架植入provisionalSBstenting.32整理課件pptThereversecrushorinternalcrushtechnique

優(yōu)點:可以保證兩條分支的立刻開通，6Fguidingcatheter可以完成操作。缺點:由于有多層支架金屬，導絲和球囊再次通過較困難，操作復雜。33整理課件pptThestepcrushtechniquedoublekissing34整理課件pptCase:Thestepcrushtechnique35整理課件ppt36整理課件pptFirstkissing37整理課件ppt38整理課件pptSecondkissing39整理課件pptFinalresult40整理課件pptThestepcrushtechnique優(yōu)點:6Fguidingcatheter可以完成操作，特別適合于橈動脈經(jīng)路，第二次導絲和球囊再次通過較容易成功。缺點:同thestandardcrushtechnique.41整理課件pptTheinvertedcrushtechnique42整理課件pptTheinvertedcrushtechnique適用于分支管徑不小于主支的情況。分支支架擠壓crush主支支架。缺點:同thestandardcrushtechnique.43整理課件pptRestenosisinMV=12.2%RestenosisinSB=2%Galassietal.Cath&Cardiovas.Intervn2007;69:976-8344整理課件pptTheculottesstentingtechnique45整理課件pptTheculottesstentingtechnique優(yōu)點:適合于任何角度的分叉病變，并提供完美的分支開口覆蓋。缺點:分叉病變近段雙層支架重疊，金屬密度高。46整理課件pptNordicBifurcationStudyII-TheNordicStentTechniqueStudy:CrushvsCulottestenting47整理課件pptNordicBifurcationStudyII-TheNordicStentTechniqueStudy:CrushvsCulottestentingIndividualend-pointat6months48整理課件pptTheYstentingtechnique49整理課件pptTheskirttechnique50整理課件pptTheYstentingtechnique

andTheskirttechnique優(yōu)點:這是最后一種治療分叉病變的方法，適用于非常復雜的分叉病變并要求保證導絲進入兩分支。缺點:近端支架釋放系統(tǒng)需要改良，手工將支架捻在雙球囊上。應用DES易破壞polymer。近端支架很難完全連接遠端雙支架。采用Y支架技術時，多數(shù)術者將分支導絲回撤并放入主支，這時釋放近端支架可以更好連接遠端支架51整理課件pptTheYstentingtechnique77casebeingwithbifurcationlesions