冠脈分叉病變不同介入治療策略評(píng)價(jià)

冠脈分叉病變不同介入治療策略評(píng)價(jià)阜外心血管病醫(yī)院楊偉憲2010-7-242010-7Accountfor15-20%ofPCIWhyanindivdualizedapproach?VariationsinAnatomyLeftmainbifurcationdiseasePlaqueburden&locationofplaqueAnglebetweenMBandSBDynamicchangesinanatomyduringtreatmentPlaqueshiftDissection

NotwobifurcationsareidenticalAnappropriatestrategyfromtheoutsetsavestimeandminimizescomplicationBifurcationPCI分叉病變分型DukeClassificationSanbornClassificationIakovouI,GeL,ColomboA.JACC,2005;46:1446-1455.SafianClassificationIakovouI,GeL,ColomboA.JACC,2005;46:1446-1455.LefevreClassificationIakovouI,GeL,ColomboA.JACC,2005;46:1446-1455.MedinaClassificationMedinaetal.RevEspCardiol.2006;59(2):183-4.分叉病變介入治療策略單支架二個(gè)支架單個(gè)支架或二個(gè)支架?A)如果分支血管的開口部位或其附近有明顯的病變，其血管直徑足夠大，從安全性和PCI的療效來考慮應(yīng)該置入兩個(gè)支架。B)在其他情況下，應(yīng)置入一個(gè)支架andthenevaluate當(dāng)前，大家公認(rèn)和使用的分叉病變治療策略是分支血

管Provisional支架術(shù)。然而仍有許多分支血管其解剖結(jié)構(gòu)（直徑較大，病變較為彌漫）需要置入兩個(gè)支架。

WhatTypeofBifurcationsare

CommonlyTreated?Majority(65%)are“True”bifurcationsExtentofSBdiseasemaydeterminestrategyNon-LMBifstreatedinMilan(n=320).ExtentofSBdisease:0 18%<5mm 27%5-10mm 19%>10mm 36%分叉病變介入治療技術(shù)分支血管通暢技術(shù)(KIO)必要時(shí)置入第二個(gè)支架（Provisional2ndstent）雙支架術(shù)分支血管通暢技術(shù)(KIO)當(dāng)分支血管開口病變或彌漫性病變，并且分支血管不適合置入支架時(shí)（太細(xì)小）或者分支血管和臨床癥狀不相關(guān)時(shí)主支和分支血管分別放入導(dǎo)引鋼絲如果需要擴(kuò)張主支血管主支血管置入支架，分支血管保留導(dǎo)引鋼絲后擴(kuò)張主支血管，分支血管保留受壓的導(dǎo)引鋼絲不要再次把導(dǎo)引鋼絲放入分支血管或者后擴(kuò)張或預(yù)擴(kuò)張分支血管

Provisional支架當(dāng)分支血管病變程度極輕或者病變僅位于分支血管開口處并且分支血管解剖結(jié)構(gòu)適合置入支架者主支和分支血管放入導(dǎo)引鋼絲擴(kuò)張主支血管，必要時(shí)擴(kuò)張分支血管主支血管置入支架，分支血管保留導(dǎo)引鋼絲分支血管再次放入導(dǎo)引鋼絲，然后撤出受壓的原導(dǎo)引鋼絲球囊對(duì)吻如果分支血管出現(xiàn)次佳結(jié)果則在分支血管置入支架（T支架術(shù)或ReverseCrush）保護(hù)分支血管術(shù)前冠脈造影前降支－對(duì)角支病變前降支置入支架Xience3.0x28mm支架術(shù)后對(duì)角支POBA球囊3.0x20mm前降支－對(duì)角支病變最終結(jié)果Wirebothbranchesandpre-dilatethemainandthesidebranchasrequired.Step1:StenttheMBjailingtheSBwireIftheresultinSBunsatisfactoryduetoplaqueshiftordissectionandSBhastobestented,thenre-crossintotheSBthroughtheMBstentstrutsStep2:TheT-stentingwithProtrusionTechnique(TAP)asaCross-overfromthe

ProvisionalApproachPositionstentinSBensuringcoverageofostiumwithminimalprotrusionintoMBandplacenon-compliantballooninMBstentFinalResult:InflatethedeliveryballoonintheSBandtheMBballoonsimultaneouslyStep3:Step4:TheT-stentingwithProtrusionTechnique(TAP)asaCross-overfromthe

ProvisionalApproach1:RewiresidebranchandadvanceaballoonanddilatetowardSB2:PositionastentintheSBwithminimalprotrusionintheMB.LeaveaballoonintheMBEVALUATERESULT:iftheresultisnotacceptablethenAReverseCrushStenting3:DeploythestentintheSBandremovethewireandtheballoon4:CrushtheshortprotrudingpartofSBstentoverthestentinMBbyinflatingtheMBballoonBReverseCrushStenting5:RewiretheSBandperformhighpressuredilatation6:PerformfinalkissingballooninflationCReverseCrushStenting雙支架術(shù)當(dāng)分支血管的病變比較彌漫，不僅僅局限于分支開口部位，并且分支血管適合置入支架主支和分支血管放入導(dǎo)引鋼絲擴(kuò)張主支血管，必要時(shí)擴(kuò)張分支血管Crush支架術(shù)或其他雙支架術(shù)如果進(jìn)行Crush:分支血管再次放入導(dǎo)引鋼絲,對(duì)其進(jìn)行高壓球囊擴(kuò)張球囊對(duì)吻擴(kuò)張Crush支架術(shù)標(biāo)準(zhǔn)Crush：7F以上指引導(dǎo)管,事先對(duì)兩個(gè)支架定位，然后釋放分支血管支架，主支血管支架擠壓分支血管支架Reverse（Internal）Crush：行Provisional支架術(shù)時(shí)需要在分支血管置入另一個(gè)支架時(shí)采用。6F指引導(dǎo)管，首先釋放主支血管支架，通過主支支架的側(cè)孔置入分支血管支架，通過預(yù)留在主支的球囊對(duì)分支血管支架進(jìn)行擠壓InverseCrush：

操作過程類似標(biāo)準(zhǔn)Crush支架術(shù)，但是分支血管的支架定位比主支血管更為近端，分支血管的支架去擠壓主支血管支架StepCrush：與標(biāo)準(zhǔn)Crush技術(shù)相同，但可在6F指引導(dǎo)管進(jìn)行StentingTechniquesfortheTreatmentBifurcationLesionsLouvardY,LefevreT,MoriceMC,etal,Heart2004;90:713-22ClassicTbeginningSBModifiedTCrushClassicTbeginningMBProvisionTCullotteTouchingstentsTrouserlegsandseatKissingstentsSkirttechnique分叉病變包括左主干病變的治療方法真性分叉病變(主支和分支血管明顯狹窄)非是主支血管置入支架，分支血管進(jìn)行球囊擴(kuò)張

分支血管適合支架術(shù)分支血管病變，從開口向遠(yuǎn)端彌漫超過3mm以上選擇性置入兩個(gè)支架（主支和分支）分支血管Provisional支架術(shù)分支血管Provisional支架術(shù)或KIO非是非是絕大多數(shù)分叉病變?cè)诮槿胫委熃Y(jié)束時(shí)需要保持分支血管通暢，殘余狹窄似乎意義不大如果分支血管達(dá)到最佳結(jié)果比較重要，在真性分叉病變中至少有50％的患者需要置入兩個(gè)支架分叉病變總結(jié)1支架策略

只有臨床需要才進(jìn)行冠脈造影隨訪BMSera:Onestentisbetter!%TVREnd-pointat6months(%)p=NSNORDICBifurcationStudySteigenTKetal.Cir,2006,114:1955-61.MACEat6months（%）p=NSNORDICBifurcationStudySteigenTKetal.Cir,2006,114:1955-61.MIrelatedtotheprocedure(％)p=0.008NORDICBifurcationStudySteigenTKetal.Cir,2006,114:1955-61.StentThrombosis(%)p=NSNORDICBifurcationStudySteigenTKetal.Cir,2006,114:1955-61.NordicStentTechniqueStudyARandomizedStudyofCrushvs.CulotteStentTechniqueswithSirolimusElutingStentsinBifurcationLesionsErglisAetal.CircCardiovascIntervent,2009;2:27-34Crush(n=209)Culotte(n=215)Pvalue

MACE4.3%3.7%0.87Procedure-relatedBio-markersincrease15.5%8.8%0.08InsegmentRestenosis12.1%6.6%0.10InstentRestenosis10.5%4.5%0.046NordicII:NordicIII:AProspectiveRandomizedTrialofSideBranchDilatationStrategiesinPatientswithCoronaryBifurcationLesionsUndergoingTreatmentwithaSingleStentNOKISSINGKISSING%2.92.9PrimaryendpointMACE(cardiacdeath,indexlesionMI,TLR,stentthrombosis)after6monthsnsNiemelaM.TCT2009BBCONEStudy

PRIMARYENDPOINT

Composite(9months)Death,MI,TVFSimpleComplexPvalue

Death0.4%0.8%-

Myocardialinfarction3.6%11.2%0.001

Targetvesselfailure5.6%7.2%0.43

Primaryendpoint8.0%15.2%0.009HR2.02(1.17to3.47)DavidHildick-Smithetal.Cir2010;121:1235-1243BBCONEStudy

PROCEDURALENDPOINTSimpleComplexPvalueProcedureTime,min5778<0.001FluoroscopyTime,min1522<0.001Diamentor,cGy-cm261407900<0.001No.ofGuidewiresUsed2.23.1<0.001No.ofBalloonUsed2.34.0<0.001No.ofStentsUsed1.22.2<0.001DavidHildick-Smithetal.Cir2010;121:1235-1243*OnenoncardiacdeathduetoischemicstrokeCACTUSStudy(CoronaryBifurcations:ApplicationoftheCrushingTechniqueUsingSirolimus-ElutingStents)ColomboA,etal.Circulation.2009;119(1):71-8EndpointCrush(%)ProvisionalT(%)Main-branchbinarystenosis4.66.7Side-branchbinaryrestenosis13.214.7MI0.50.5TLR5.65.8TVR6.26.8Death00.5*Stentthrombosis1.71.1InfluenceofFinalKissingintheCACTUStrialColomboA,etal.Circulation.2009;119(1):71-8EndpointFinalKissing(163pts)NoFinalKissing(14pts）PvalueMain-branchstenosis4.7%16%0.03Side-branchrestenosis11.9%36%0.001MI7.5%29%0.001TLR6.3%12.9%0.25Stentthrombosis0.9%6.5%0.060.60.40.2MainBranchSideBranch051015202530354015.5%(9/58)8.9%(8/90)37.9%(22/58)11.1%(10/90)0.210.34P=0.10P<0.05P=0.33P<0.001Restenosis(%)LLL(mm)0.320.52ImportantRoleoffinalkissingballooninCrushTechniqueGeL,etal.JACC,2005;46:613-620.WithoutFKBFKBKissme,Kate!9MonthClinicalOutcomesAfterCrushStentingGeL,etal.JACC,2005;46:613-620.T-stenting(n=61)Crushingstenting(n=121)T-StentingVS.CrushingStenting14.0%

TLR TVR TLR TVR31.1%16.5%32.8%14.1%11.3%28.9%31.1%ENTIRECOHORT05101520253035KISSINGBALLOONP=0.01P=0.02P=0.03P=0.04GeL,etal.Heart,2006;92:371-376GeL,etal.Heart,2006;92:371-376MiniCrushwithDoubleKissingJIMMH,etal.CCI,2007,69:969-975Non-randomizedcomparison;457pati