分叉病變治療策略

PCI的治療策略和器械選擇（各論）分叉病變分叉病變“雪橇效應(yīng)”——斑塊的軸向移位Lefevre分型IakovouI,GeL,ColomboA.JACC,2005;46:1446-1455.Medina分型Medinaetal.RevEspCardiol.2006;59(2):183-4.MB(Proximal)MB(Distal)SB0,10,10,11,1,11,1,01,0,10,1,11,0,00,1,00,0,1Chen氏分型主支+邊支病變主支病變邊支病變分叉病變的處理策略單支架術(shù)：KIO;ProvisionalT雙支架術(shù)T支架術(shù)CRUSHCULOTTESKS(simultaneouskissingstents)TAP(TAndProtrusion)分支的KIO技術(shù)Tokeepitopen以下情況需要進(jìn)一步處理分支：

1）分支血流＜TIMI3級，

2）分支開口明顯受壓（＞90%）3）分支血管瀕臨閉塞，

4）分支夾層＞A型

支架的釋放壓力不應(yīng)過高交換導(dǎo)絲穿過支架網(wǎng)眼過程中避免將導(dǎo)絲拉至支架近端外應(yīng)選擇profile小的球囊穿過網(wǎng)眼，壓力不宜過高應(yīng)避免在邊支使用親水涂層導(dǎo)絲分叉病變一般操作示意圖保護(hù)分支血管術(shù)前冠脈造影前降支－對角支病變前降支置入支架Xience3.0x28mm支架術(shù)后對角支POBA球囊3.0x20mm前降支－對角支病變最終結(jié)果臨時分支支架技術(shù)Provisionalstent，先在主支植入支架下述情況可考慮植入第二個支架：

1）分支大，血流＜TIMI3級

2）球囊加壓處理后分支開口明顯受壓

3）分支血管瀕臨閉塞，

4）球囊擴(kuò)張后分支血管出現(xiàn)明顯夾層ProvisionalT操作要點單支架覆蓋主支，根據(jù)情況考慮是否再處理邊支操作步驟：一根或兩根導(dǎo)絲：如邊支粗大且可能受累，置入導(dǎo)絲保護(hù)主支球囊預(yù)擴(kuò)后植入支架如邊支受累不明顯，或邊支細(xì)小，則結(jié)束手術(shù)如邊支血流受影響，且足夠大，考慮于邊支植入支架（Provisional）ProvisionalT的器械選擇強(qiáng)支撐力導(dǎo)管：EBU、XB、AL一般情況下工作導(dǎo)絲即可，如BMW、Runthrough、ATW少數(shù)情況下邊支開口角度大時，可能需要扭控性更強(qiáng)的軟導(dǎo)絲：ASAHINEO’S

系列、ACS的HI-TORQE系列邊支保護(hù)導(dǎo)絲禁用超滑涂層導(dǎo)絲：PT2、Pilot選用網(wǎng)眼較大的支架：PE、Resolute、XienceV

如果球囊擴(kuò)張不滿意，可以考慮分支支架ProvisionalT

示意圖雙導(dǎo)絲到位釋放主支支架交換導(dǎo)絲球囊擴(kuò)張分支NordicBifurcationStudy(n=413)413ptswithbifurcationlesion

Stentingofthemainvesselandside

branch(MV+SB)Stentingofthemainvesselandoptionalstentingofthesidebranch(MV)n=206n=207RandomizedPrimaryEndpoint:Majoradversecardiacevent(MACE)at6monthsPrimaryEndpointofMACEat6months(%)p=NSPresentedatACC2006Therewasnodifferenceinmajoradversecardiaceventsat6months(17.7%vs12.7%;p=NS)NordicBifurcationStudy(n=413)ProcedurerelatedMIwasdefinedasafive-foldelevationofbiochemicalmarkersProcedurerelatedMIoccurredmorethanthreetimesasoftenintheMV+SBgroup(13%vs4%;p=0.008)ProcedureRelatedMyocardialInfarction(%)p=0.008PresentedatACC2006NordicBifurcationStudy(n=413)9-monthresultsofBBCONETrial

n=250n=250TCT2008P=0.009P=0.001P=0.003Composite=Death,MI,TVF雙支架術(shù)盡量應(yīng)用單支架覆蓋下列情況考慮直接采用雙支架術(shù)：邊支粗大，≥2.5mm且開口存在顯著而彌漫的狹窄病變TstentTechnique（邊支支架精確定位）GapinsidebranchcoveragewithProvisionalT-stentingThegapafterTstenting%p=0.20Stent+StentStent+PTCAMainbranchSidebranchColomboetal.Circulation2004;109:1244.TheBifurcationStudyWithCypherSirolimus-ElutingStentSegmentRestenosis1/4411/441/202/203.120.3MainSidebranchTotalRestenosis13/642/64

restenosisCulotteTechnique分叉近段雙層支架在分叉處及分叉近端有雙層支架需要用導(dǎo)絲掏兩次支架網(wǎng)眼可以很好地覆蓋邊支開口適用于所有角度的分叉病變（最好<70度）優(yōu)點缺點對主邊支直徑有要求：主支、邊支直徑接近，且均<3.5mmCrushTechniqueCRUSH類型經(jīng)典CRUSH球囊CRUSH（STEPCRUSH）ReverseCRUSHInverseCRUSHMiniCRUSHDKCRUSHStep(Balloon)Crush（1）雙導(dǎo)絲(2)先釋放主支支架Reversecrushingtechnique(3)導(dǎo)絲穿網(wǎng)眼進(jìn)入邊支，球囊擴(kuò)張網(wǎng)眼(4)定位邊支支架，并突入主支3-5mm，主支保留球囊(5)釋放邊支支架(6)主支球囊擴(kuò)張，擠壓邊支支架Step1:

導(dǎo)絲分別至主支和邊支遠(yuǎn)端Step2:以邊支作為主支，邊支支架近端突出更多InvertedCrush

Step1:PositionastentinSB(protrudinginMB)andpositionaballooninMBStep2:DeploytheSBstentandremovewireandballoon

Step3:CrushtheSBstentwithballoonofMBStep4:RewireSBandkissingatmediumpressureDoublekissing(DK)CrushTechniqueChenSLetal.ChineseMedicalJournal,2005Step5:AdvancestentinMBmoreproximalthanSBstent

Step6:DeployMBstentStep7:RewireSBandkissingatmediumpressureFinalresultDoublekissing(DK)CrushTechnique兩步法對吻技術(shù)的重要性無對吻1步法對吻2步法對吻CRUSH的臨床預(yù)后TLR發(fā)生率為90.3%,主支再狹窄發(fā)生率9.1%,邊支再狹窄率25.3%(HoyeA.JAmCollCardiol2006;47:1949-1958)6個月的再狹窄率11.3%(MoussaIAmJCardiol2006；97：1317－1321)EntireCohort(n=181)FKBI(n=116)Non-FKBI(n=65)P9-monthMACE(%)26.519.838.50.008

Cardiacdeath1.11.700.54

Q-waveMI3.31.76.20.28

NonQ-waveMI8.38.67.70.95

TLR14.99.524.60.008

TVR17.110.329.20.002Stentthrombosis2.82.63.10.78

Subacute0.601.50.77

Late2.22.61.50.95“Crush”Stenting的臨床預(yù)后Geetal,JAmCollCardiol2005FKBI=finalkissingballooninflation——對吻很重要！“Crush”Stenting的長期預(yù)后再狹窄率%

MainVesselSide-BranchWithoutKissingBalloonAngioplasty(n=67)KissingBalloonAngioplasty(n=118)15.5P=0.338.911.137.9P<0.001

MainVesselSide-BranchGeetal,JAmCollCardiol2005P=0.10P=0.04mm0.340.210.520.32晚期管腔丟失——對吻很重要！分叉近端血管壁有三層支架不是所有患者均能完成最終對吻:<87.5%能很好地覆蓋邊支開口能在術(shù)中確保兩支血管都開通過優(yōu)點缺點支架血栓(~4.3%)和TLR

(8~24%)的發(fā)生率相對較高Nordic-BalticPCIStudyGroup:independentworkinggroupofinterventionalcardiologistsintheNordicandBalticcountriesArandomizedtrialtocompareCRUSHvs.CULOTTEbifurcationstenttechniquesusingCYPHERstentsTheNordicBifurcationStentTechniqueStudyGunnesetal.ACC08Randomization(n:424)CRUSH(n:209)CULOTTE(n:215)ClinicalFollowup,6months(n:209)ClinicalFollowup,6months(n:215)ScheduledAngiographicFollowup,8months(n:184)ScheduledAngiographicFollowup,8months(n:189)AngiographicFUavailable(n:160)AngiographicFUavailable(n:164)n:424(100%)n:424(100%)n:373(88%)n:324(87%)StratificationatrandomizationCrush-stentingCulotte-stentingNORDICII:6個月