復(fù)雜冠脈分叉病變的pci治療策略

1、PCI Strategies for Complex Coronary Bifurcation lesions,首都醫(yī)科大學(xué)附屬北京安貞醫(yī)院 周玉杰 聶斌 Beijing Anzhen Hospital,One or two stents?,Nordic Bifurcation Study (n=413),413 pts with bifurcation lesion,Ste

2、nting of the main vessel and side branch (MV+SB),Stenting of the main vessel and optional stenting of the side branch (MV),,,n=206,n=207,Randomized,Primary Endpoint: Major adverse cardiac event (MACE

3、) at 6 months,,Primary Endpoint of MACE at 6 months (%)p=NS,Presented at ACC 2006,There was no difference in major adverse cardiac events at 6 months (17.7% vs 12.7%; p=NS),Nordic Bifurcation Study (n=413),,Procedure re

4、lated MI was defined as a five-fold elevation of biochemical markersProcedure related MI occurred more than three times as often in the MV+SB group (13% vs 4%; p=0.008),Procedure Related Myocardial Infarction (%)p=0.0

5、08,Presented at ACC 2006,Nordic Bifurcation Study (n=413),One Stent Strategy,Provisional T Stenting,,,,,,,Provisional T Stent,,,Provision-T stent technique,53 pts, SB>2mmMACE 9.4% at 14+/-3 monthsTLR 3.8%, MV r

6、estensosis 3.2%, SB 12.9% at 6 months,,Vigna C, et al. J Invasive Cardiol. 2007 Mar;19(3):92-7.,,The SB has a narrowing at its ostium,,The MB has severe stenosis with a large plaqueburden and the SB originates with an a

7、ngle of 45°,The ostium of the SB deteriorates after pre-dilatation of the MB,A wire is needed in the following circumstances:,,Provisional T Stent,,FKB is Very Important for Provisional T Stent,Provisional T Stent,

8、,Two Stents Techniques,,T stentCulotte SKS V stentProvisional TModified T stentY stent,BMS Era,DES Era,,Crush,Reverse Crush,Balloon Crush,DK Crush,Mini-Crush,Inverted Crush,,,,,,,,,T stent Technique,,,,,,,,Culotte

9、 Technique,,Clinical Outcomes,In BMS era, the incidence of TLR was 24% at 6 months (Chevalier. Am J Cardiol 1998;82:943) In DES era, the incidence of MACE was 5.3% and TLR was 15.4% (Hoye, et al. Int J Cardiovasc int

10、erven 2005;7:36),Culotte vs T stent in DES era,80 patients with bifurcation lesions,Culotte technique 45 cases,T stent 35 cases,The procedural success rate 100% TLR: 8.9% P = 0.014 ;9monthsMACE 13.3% P=0.051,Kaplan

11、 S, et al. Am Heart J. 2007 Aug;154(2):336-43,The procedural success rate 100% TLR: 27.3% 9monthsMACE 27.3%,,,,,,,,,,,SKS Technique,Clinical Outcome,200 patients with bifurcation lesions,SKS technique,Cypher stents,,,

12、The clinical success rate is 97%The incidence of TLR: 4% 9+/- 2 months,,Sharma SK. Catheterization and Cardiovascular Interventions 2005;65:10,Clinical Outcome,36 patients with bifurcation lesions,SKS technique,SES ste

13、nts 26.7+/-8.6 month,,,The procedure success rate is 100%No MACE, MB restenosis13%, SB 10%The incidence of TLR: 14%,,,Kim YH, et al. Catheter Cardiovasc Interv. 2007 Nov 15;70(6):840-6,,,,,,,,Y Stent Technique,,,,

14、,,,,Crush Technique,,Clinical Outcomes,The survival rate free of TLR was 90.3%, incidence of restenosis at MB was 9.1%, restenosis at SB was 25.3% (Hoye A . J Am Coll Cardiol 2006;47:1949-1958 ) Incidence of TLR at 6

15、 month follow-up is 11.3% (Moussa I Am J Cardiol 2006；97：1317－1321),,,Colombo et al. PCR 2004,Final Kissing is very important !,,,,,,,,,,,,,,,,,,,,,,,,,Step 1: Wire both branches and predilate both,Step 2: Both stents in

16、 place.Side-branch stent positioned more proximal,Inverted Crush,,,Wire both branches and predilate,,,,,,,,,,,,Deploy stent in main branch,,,,Reverse crushing technique,,,,,,,,,,,,,,,,,,,,,,,,,,Wire side branch and dila

17、te,,Position stent in side branch protruding in MB (slight), leave a balloon in MB,,,,,,,,,,Deploy stent in the side branch and remove wire and balloon,,,,,,,,,,,,,,,,,,,,,,,,Crush the protruding part of SB on top of th

18、e stent in MB,Balloon Crush,DK Crush ( Sleeve Technique),,mini-crush,45 pts, 52lesionsProcedural success 100%No in-hospital MACETLR 12.2%, MV restensosis 12.2%, SB 2% at 8 months,,Galassi AR, et al. Catheter Cardiova

19、sc Interv. 2007 1;69(7):976-83,,TAP technique,Wire both branches and predilate,Deploy stent in main branch,,Wire side branch and dilate,Kissing balloon,,SB stent positioning,SB stent is deployed with theuninflated ball

20、oon into the MV,,The balloon of the SB stent is slightly retrieved and aligned to the MV balloon,Final kissing balloon,In vitro TAP stenting,Perfect coverage of the bifurcation withminimal stent’s struts overlap at the

21、proximal part of SB ostium,,,,0.070”0.071’’,0.078”,6F,7F,,,≤5.3F,5.4F ～5.9F,Tips and tricks,Size of Guiding Catheter,MV balloon shaft profile + SB stent shaft profile,,,8F,≥6.0F,0.088”,6 F,7 F,8 F,GC,5.4F﹥0.070″﹥5.3F,6F

22、導(dǎo)管完成對(duì)吻擴(kuò)張,6F導(dǎo)引導(dǎo)管的內(nèi)徑：0.070〞0.071),兩球囊推送桿外徑之和應(yīng)≤5.3F,6F導(dǎo)引導(dǎo)管進(jìn)行球囊對(duì)吻技術(shù),,球囊外徑：2.9F+2.6F=5.5F 6F導(dǎo)管內(nèi)徑：0.070 inch﹤5.4F,選用導(dǎo)引導(dǎo)管：6F JL 3.5,,,Case of TAP stenting,Coronary Angiography,6F EBU 3.5,,BMW,BMW,3.0×24mm Cypher,Deployme

23、nt MV stent with jailed guidewire into the SB,,,Kissing balloon after rewiring of SB,,SB stent positioning,,SB stent,,MV balloon,,The position of the SB stent is adjusted to fully cover the proximal part of the SB ostium

24、 (red arrow) while an uninflated balloon kept into the MV,,SB is deployed with the uninflated balloon into MV,SB stent deployment,Final kissing balloon,,The balloon of the SB stent is slightly retrieved and aligned to t

25、he MV balloon,,,Final kissing balloon SB stent’s balloon ＋ MV balloon,Final Result,,Clinical study of TAP,,Burzotta F, et al. Catheterization and Cardiovascular Interventions 2007, 70:75–82,,

26、Angiographic characteristics,,Procedure characteristics,,Clinical outcome (9 month),,Strategies for LMCA lesions,Stent implantation in the side branch?,,,,,No,Yes,6F Guiding Catheter,Treatment Strategy,,,,,,Balloon/DK/Re

27、verse crushProvisional T stent/Culotte,,Standard crush/SKSModified T stent,,,6F Guiding Catheter,7F Guiding Catheter,,Select the size of GC,,,116 pts with LMCA bifurcation lesions,,,,,Cross-over (n=67),Complex s

28、trategy (n=49),,,,,SKS (n=24),Crush (n=25),Kim YH, et al. Am J Cardiol. 2006 ;97(11):1597-601,,,,,,Compared to the complex stenting approach, the simple approach (stenting cross-over) was technically