冠脈分叉病變介入技巧

冠脈分叉病變介入技巧ClassificationofbifurcationlesionsaccordingtoplaqueburdenA:DukeB:SanbornC:SafianD:LefevreMedinaA.etal.RevEspCardiol.2006;59:183-4ANewClassificationofCoronaryBifurcationLesions-MedinaClassification1,1,11,1,01,0,10,1,11,0,00,1,00,0,1MBDistalMBProximalSB一個(gè)好還是兩個(gè)好？如果選２個(gè)，應(yīng)該采取何種策略?策略選擇的根據(jù)簡(jiǎn)單化vs復(fù)雜化循證結(jié)果vs個(gè)人選擇并發(fā)癥率(especiallyMI/thrombosis)分叉病變介入治療

-關(guān)注熱點(diǎn)Stentingforbifurcationlesionsin2007主支放支架，分支臨時(shí)決定StentingthemainvesselwithprovisionalstentingofthesidebranchProvisionalStentingStrategy

If2ndstentisneededforsidebranchfollowingmainvesselstentingModifiedT-stentingReversecrushing Culottestenting 分支血管的保護(hù)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(shí)施分支血管保護(hù)和支架植入分支血管大小與分布區(qū)域分支血管開(kāi)口病變與病變程度分支與主支成角程度TheTandmodifiedTstentingtechniqueSide-branchcompromisebystentmaterialRestenosisinMV=12.VstentingvsTstentingProvisionalStentingStrategy近端支架釋放系統(tǒng)需要改良，手工將支架捻在雙球囊上。Galassietal.OstialspasmorVstentingvsTstenting近端支架釋放系統(tǒng)需要改良，手工將支架捻在雙球囊上。NordicBifurcationStudyIINordicBifurcationStudyIITheVstentingtechniqueCulottestenting適合于分叉病變位于接近開(kāi)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(wú)病變。SidebranchclosureafterPCISide-branchmaybecompromisedfollowingmainvesselstentingPre-treatmentAfterstentingPlaqueshifting(“Snow-plow”)OstialspasmorSide-branchcompromisebystentmaterialDissectionofplaqueatoriginofside-branchDissectionflapatmainarteryobstructingoriginofside-branchAttimes,thesidebranchcouldbecompromisedbythrombustooDifferenttechniquesoftwostentsbyintentiontotreatbifurcationlesionsTheVstentingtechniqueThesimultaneouskissingstentstechniqueTheTstentingandmodifiedTstentingtechniqueThecrushtechnique(Thereversecrushtechnique/Thestepcrushtechnique/Theinvertedcrushtechnique)TheculottesstentingtechniqueTheYstentingtechniqueTheskirttechniqueTheVstentingtechniqueThesimultaneouskissingstentstechniqueTheVstentingandthesimultaneouskissingstentingtechnique適合于分叉病變位于接近開(kāi)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(wú)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(wú)病變或無(wú)須支架。

主要用于臨時(shí)分支支架植入provisionalSBstenting.可以保證兩條分支的立刻開(kāi)通,這點(diǎn)對(duì)保護(hù)功能上重要的分支非常重要。Dissectionofplaqueatoriginofside-branchLefevreetal:ProvisionalTstentingisthegoldenstandardtotreatfalsebifurcationlesion(tpye2,3and4a),mostsubjectsonlyneedonestentimplantation。RestenosisinSB=2%ThestepcrushtechniqueVstenting:100分叉病變介入治療

-關(guān)注熱點(diǎn)TheVstentingtechniqueGalassietal.ProvisionalStentingStrategyTheTandmodifiedTstentingtechniqueThereversecrushorinternalcrushtechniqueColomboetalCirculation2004;109:1244-1249ThecrushtechniqueTheVstentingandthesimultaneouskissingstentingtechnique優(yōu)點(diǎn):保證不會(huì)丟失分支。

對(duì)吻技術(shù)時(shí)無(wú)須re-crossanystent.TheVstentingandthesimultaneouskissingstentingtechnique缺點(diǎn):雙支架近端定位較困難；不可避免造成其中一個(gè)支架偏心，往往引起agap。TheTstentingtechniqueThemodifiedTstentingtechniqueTheTandmodifiedTstentingtechnique優(yōu)點(diǎn):較crush技術(shù)容易完成。缺點(diǎn):大多數(shù)情況下，分支開(kāi)口不能完全覆蓋。ColomboetalCirculation2004;109:1244-1249*Highcross-overratefromStent+BalloontoStent+Stentgroup(22/43,51%)CypherBifurcationStenting(T-stenting)EffectsoftheTstentingtechniqueRESEARCHbifurcationsubgroupRRofdifferenttechniquesThehighrestenosisrateofTstentingtechniquemayberelatedtotheincompletecoverageofstentingbeinglocatedattheostiumofSB.TanabeK,HoyeA,LemosPA,etal.AmJCardiol,2004,91:115-8EffectsoftheTstentingtechniqueVstentingvsTstentingSharmaetal.Vstenting:100ProvisionalTstenting:10032%subjectsreceivedCypherstentandRVDwas3.32mm。ProvisionalTstenting優(yōu)點(diǎn):HigherproceduralsuccessrateLowerexpenseLowercomplicationsLowerre-PCI7monsTLR<15%。Lefevreetal:ProvisionalTstentingisthegoldenstandardtotreatfalsebifurcationlesion(tpye2,3and4a),mostsubjectsonlyneedonestentimplantation。ProvisionalTstentingThecrushtechniqueThecrushtechnique優(yōu)點(diǎn):可以保證兩條分支的立刻開(kāi)通,這點(diǎn)對(duì)保護(hù)功能上重要的分支非常重要?？梢酝耆采w分支開(kāi)口。缺點(diǎn):由于有多層支架金屬，導(dǎo)絲和球囊再次通過(guò)較困難，操作復(fù)雜。Geetal.JACC2005;46:613Longtermoutcomeof“Crush”Stentingtechnique6monsRRColomboetal.ThecrushtechniqueThereversecrushorinternalcrushtechniqueThereversecrushorinternalcrushtechnique主要用于臨時(shí)分支支架植入provisionalSBstenting.

Thereversecrushorinternalcrushtechnique

優(yōu)點(diǎn):可以保證兩條分支的立刻開(kāi)通，6Fguidingcatheter可以完成操作。缺點(diǎn):由于有多層支架金屬，導(dǎo)絲和球囊再次通過(guò)較困難，操作復(fù)雜。ThestepcrushtechniquedoublekissingCase:ThestepcrushtechniqueFirstkissingTheinvertedcrushtechniqueThestepcrushtechniqueIf2ndstentisneededforsidebranchfollowingmainvesselstentingSidebranchclosureafterPCIThecrushtechniqueTheTstentingtechnique近端支架釋放系統(tǒng)需要改良，手工將支架捻在雙球囊上。適用于分支管徑不小于主支的情況。2006;59:183-4ProvisionalStentingStrategy主要用于臨時(shí)分支支架植入provisionalSBstenting.FirstkissingVstenting:100ColomboetalCirculation2004;109:1244-1249雙支架近端定位較困難；SecondkissingFinalresultThestepcrushtechnique優(yōu)點(diǎn):6Fguidingcatheter可以完成操作，特別適合于橈動(dòng)脈經(jīng)路，第二次導(dǎo)絲和球囊再次通過(guò)較容易成功。缺點(diǎn):同thestandardcrushtechnique.TheinvertedcrushtechniqueTheinvertedcrushtechnique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(diǎn):同thestandardcrushtechnique.RestenosisinMV=12.2%RestenosisinSB=2%Galassietal.Cath&Cardiovas.Intervn2007;69:976-83TheculottesstentingtechniqueTheculottesstentingtechnique優(yōu)點(diǎn):適合于任何角度的分叉病變，并提供完美的分支開(kāi)口覆蓋。缺點(diǎn):分叉病變近段雙層支架重疊，金屬密度高。NordicBifurcationStudyII-TheNordicStentTechniqueStudy:CrushvsCulottestentingNordicBifurcationStudyII-TheNordicStentTechniqueStudy:CrushvsCulottestentingIndividualend-pointat6monthsThesimultaneouskissingstentstechniqueVstenting:100CypherBifurcationStentingThe