分叉病变的介入治疗候静波教授.pdf

1、冠脉分叉病变的介入治疗哈医大二院心血管病医院哈医大二院心血管病医院侯静波侯静波让我们先从一个病例开始让我们先从一个病例开始病例资料6060岁男患；岁男患；发作性心前区疼痛发作性心前区疼痛6 6年年,加重加重1 1个月个月既往高血压病史既往高血压病史,糖尿病史糖尿病史1010年，最高血压年，最高血压160/110mmHg160/110mmHg；长期吸烟史长期吸烟史4040年，无饮酒史；年，无饮酒史；入院时肝功肾功及相关化验检查基本正常。入院时肝功肾功及相关化验检查基本正常。病例资料在外院行在外院行PCIPCI治疗治疗2 2次，第一次于前降支植入支架一次，第一次于前降支植入支架一枚（枚（0909年

2、年1010月），月），1010年年6 6月因有症状再行冠脉造影月因有症状再行冠脉造影发现为前降支、第一对角支真分叉病变发现为前降支、第一对角支真分叉病变,因冠脉钙因冠脉钙化较重化较重,行行IVUSIVUS检查后检查后,过程中造成前降支、对角过程中造成前降支、对角支急性闭塞，紧急于前降支植入支架，对角支未能支急性闭塞，紧急于前降支植入支架，对角支未能开通，患者开通，患者PCIPCI后反复有不稳定心绞痛发生，后反复有不稳定心绞痛发生，2020天天后来我院。后来我院。外院造影结果外院造影结果外院PCI过程外院PCI过程试图恢复对角支血流未果试图恢复对角支血流未果外院PCI过程外院PCI过程紧急于前降

3、紧急于前降支植入支植入2 2枚枚支架后支架后病例资料患者因患者因PCIPCI后反复有不稳定心绞痛发生，较以往加后反复有不稳定心绞痛发生，较以往加重，重，2020天后来我院。天后来我院。造影结果造影结果治疗策略患者前降支有轻度重构，对角支闭塞，左冠提供对患者前降支有轻度重构，对角支闭塞，左冠提供对角支少量的侧枝循环；角支少量的侧枝循环；患者临床症状比较明显，但临床检查并无确切的缺患者临床症状比较明显，但临床检查并无确切的缺血证据，是否有进一步血证据，是否有进一步PCIPCI，开通对角支的必要？，开通对角支的必要？OCT检查对角支远段多层对角支远段多层支架支架对角支开口处有对角支开口处有血栓，并无

4、明显血栓，并无明显钙化，可看到开钙化，可看到开口缝隙口缝隙近端支架近端支架贴壁尚可贴壁尚可治疗策略 患者对角支血流不充分，且开口提示血栓性患者对角支血流不充分，且开口提示血栓性病变，考虑还是上次病变，考虑还是上次PCIPCI过程中急性损伤了过程中急性损伤了对角支开口所致，对角支应该还有打开的可对角支开口所致，对角支应该还有打开的可能，决定尝试能，决定尝试PCIPCI。PCI过程Feilder导丝未通过，导丝未通过，Pilot 150导导丝进入对角支，丝进入对角支，1.5*15mm球囊球囊PCI过程PCI过程以类似以类似provisional T支架技术及对吻扩支架技术及对吻扩张植入对角支支架张

5、植入对角支支架术后情况 患者术后心绞痛消失，运动负荷试验阴性；患者术后心绞痛消失，运动负荷试验阴性；一个决定引发了冠脉急性闭塞，被动的急诊支一个决定引发了冠脉急性闭塞，被动的急诊支架植入及择期开通对角支虽然可恢复血流，但架植入及择期开通对角支虽然可恢复血流，但患者局部支架多层，犬牙交错，远期效果还有患者局部支架多层，犬牙交错，远期效果还有待评价待评价分叉病变分叉病变Background:Bifurcation lesions15-20%of lesions treated in the cathlabStill a challenge for interventionalistsLower s

6、uccess ratesHigher incidence of procedural complicationsHigher reintervention ratesIdeal strategy of bifurcation lesion treatment is still debatedBifurcation Classification(Medina et al)Classification1 or 2 Stents:Randomized TrialsStudyNo.Pat-ientsTwo-stentStrategyType of DESThienopyridine duration,

7、moIntention to TreatAngio F/U(months)Clincial F/U(months)Pan et al91AnySES12Yes611Colombo et al85AnySES3No66NORDIC413AnySES6-12Yes86Ferenc et al.202T-stentingSES6-12Yes912,24BBC ONE500Crush or CulottePES9Yes9CACTUS350CrushSES6Yes66,12Brar et al.EuroIntervention,2009(in-press)Bifurcation Stenting Met

8、a-Analysis1101000.10.01MortalityPan et alColombo et alNORDICFerenc et al.BBC ONECACTUSOverallFavors ProvisionalFavors Two-StentRelative Risk(95%CI)1.12(0.42-3.02)P=0.820.9%Provisional0.7%Two StentBrar et al.EuroIntervention,2009(in-press)Bifurcation Stenting Meta-Analysis1101000.10.01Myocardial Infa

9、rctionPan et alColombo et alNORDICFerenc et al.BBC ONECACTUSOverallFavors ProvisionalFavors Two-StentRelative Risk(95%CI)0.57(0.37-0.87)P=0.013.6%Provisional6.8%Two StentReduction43%Brar et al.EuroIntervention,2009(in-press)Bifurcation Stenting Meta-Analysis1101000.10.01Target Lesion Revascularizati

10、onPan et alColombo et alNORDICFerenc et al.BBC ONECACTUSOverallFavors ProvisionalFavors Two-StentRelative Risk(95%CI)0.91(0.61-1.35)P=0.635.1%Provisional5.4%Two StentBrar et al.EuroIntervention,2009(in-press)Bifurcation Stenting Meta-Analysis1101000.10.01Main Branch StenosisPan et alColombo et alNOR

11、DICFerenc et al.CACTUSOverallFavors ProvisionalFavors Two-StentRelative Risk(95%CI)1.41(0.76-2.61)P=0.274.9%Provisional3.6%Two StentBrar et al.EuroIntervention,2009(in-press)Bifurcation Stenting Meta-Analysis1101000.10.01Side Branch StenosisPan et alColombo et alNORDICFerenc et al.CACTUSOverallFavor

12、s ProvisionalFavors Two-StentRelative Risk(95%CI)1.09(0.79-1.51)P=0.6014.0%Provisional13.3%Two StentBrar et al.EuroIntervention,2009(in-press)Bifurcation Stenting Meta-Analysis1101000.10.01Stent ThrombosisPan et alColombo et alNORDICFerenc et al.BBC ONECACTUSOverallFavors ProvisionalFavors Two-Stent

13、Relative Risk(95%CI)0.56(0.23-1.51)P=0.450.8%Provisional1.7%Two StentBrar et al.EuroIntervention,2009(in-press)Favors ProvisionalBifurcation Stenting Meta-Analysis11020-10-20QCA Analysis Percent Diameter Stenosis(difference in means)Pan et alColombo et alNORDICFerenc et al.CACTUSOverallFavors Provis

14、ionalFavors Two-Stent-1.08(-2.91-0.74)Brar et al.EuroIntervention,2009(in-press)11020-10-20Pan et alColombo et alNORDICFerenc et al.CACTUSOverallFavors Two-Stent1.30(-23.35-5.96)Main BranchSide Branch没有过多的分叉处病变没有过多的分叉处病变There is no too much Bifurcation lesion.分叉病变处理的必要性分叉病变处理的必要性：分支大小、分布、是分支大小、分布、是否

15、梗塞支、有无侧支循否梗塞支、有无侧支循环环分叉病变处理的可行性分叉病变处理的可行性：分支直径、成角情况分支直径、成角情况4.3%18.8%31.0%2.8%19.2%9.4%14.7%0.0%5.0%10.0%15.0%20.0%25.0%30.0%35.0%40.0%NORDICBBKC AC TUSBBC ONEC rossover from 1 stent to 2 stentsAngiographic S B restenosisHow Often We Need 2ndStent after MV Stent?Crossover from 1 Stent to 2 StentsSte

16、igen TK et al.Circulation.2006;114:1955-1961 Ferenc M et al.Eur HeartJ 2008;29:28592867 Colombo A et al.Circulation.2009;119:7178 Hildick-Smith D et al.Circulation.2010;121:1235-1243TVF due to SB restenosis 2.8%(no angio f-up)NAI N S I D E II T r i a l Pts Randomized to 1 Stent:Predictors of Cross-O

17、ver to SB StentingVARIABLEYESNOP valueQCA Lesion length,mm13.98.870.01Reference diameter2.472.510.83%DS88.671.70.02IVUSMLA,mm21.732.330.005Plaque burden65.559.10.41Remodeling index0.650.960.03Calcium(arc 90O),%83.329.30.006UnfavourableangleUnfavourable angleUnfavourable angle:mini crushFinalTrue Bif

18、urcation(significant stenosis on the main and side branches)No YesStent on MB“Keep It Open”for SBIs SB suitable for stenting?SB disease is diffuse&/or not localized to within 3 mm from the ostium?Provisional SB stentingElective implantation of two stents(MB and SB)Provisional SB stentingYesYesNo No

19、Correlation Between FFR and%Stenosis(QCA)in Jailed Side BranchesThere was a negative correlationbetween the percent stenosis and FFR(r=0.41,p0.001).No lesion with 75%stenosis had FFR1mm associated with 14%incidence of Myocardial InfarctionArora RR et al.Cathet Cardiovasc Diagn 1989;18:210-2.SB closu

20、re associated with large periprocedural MIChaudhry EC et al.J Thromb Thrombolysis 2007.Why Protect SBs from Closure?When the SB has ostial or diffuse disease AND when the SB is not suitable(too small)for stenting or clinically not relevant 6 Fr guiding catheter1.Wire both branches2.Dilate MB if need

21、ed3.Stent MB and leave wire in the SB4.Post-dilatation of MB with jailed wire in SBKeep It Open(KIO)Do not re-wire SB or postdilate or predilate SBWhen SB has minimal disease or only at the ostiumAND when SB is suitable for stenting 6 Fr or 7F guiding catheter 1.Wire both branches2.Dilate MB and SB

22、if needed3.Stent MB leaving a wire in the SB Re-wire SB and then remove jailed wire(Prowater/Rinato,BMW,Runthrough,intermediate wire,Pilot 50 or 150,feilderwire)Kissing balloon inflation Stent SB only if suboptimal result(TAP,reverse crush,culotte)ProvisionalWhen SB has disease extending beyond its

23、ostiumAND when SB is suitable for stenting 7 Fr guiding catheter1.Wire both branches2.Dilate MB and SB if needed3.Perform crush,culotte or V-stent4.If crush:rewire SB and perform high pressure SB dilatation(2-step kiss)5.Final kissing balloon inflation always!Two Stents2-Step KissNo KissOne-step Kis

24、sTwo-step KissABCSlide courtesy of John OrmistonOptimal Performance of 2 Stent Techniques Important in Reducing Event RatesImpact of learning curve in Technique;TCT 2006Bifurcational lesion with no disease proximal to the bifurcation or very short left mainBifurcational lesion with main branch disea

25、se extending proximal to the bifurcation and side branch which has origin with about 90 angleBifurcational lesion with main branch disease extending proximal to the bifurcation and side branch which ha origin with about 60 angleV-StentT-StentShort-Mini CrushCross SectionPrePostPrePostPrePostAn appro

26、ach for bifurcational lesions when using 2 stents as intention to treatThe T-stenting with Protrusion Technique(TAP)as a Cross-over from the Provisional ApproachWire both branches and pre-dilate the main and the side branch as required.Step 1:Stent the MB jailing the SB wireIf the result in SB unsat

27、isfactory due to plaque shift or dissection and SB has to be stented,then re-cross into the SB through the MB stent strutsStep 2:Position stent in SB ensuring coverage of ostium with minimal protrusion into MB and place non-compliant balloon in MB stentFinal Result:Inflate the delivery balloon in th

28、e SB and the MB balloon simultaneouslyStep 3:Step 4:The T-stenting with Protrusion Technique(TAP)as a Cross-over from the Provisional Approach1:Wire both branches and predilate if needed2:Stent the MB leaving a wire in the SB.The stent in the MB can be deployed at high pressureT stentingA3:Rewire th

29、e SB passing through the struts of the MB stent,remove the jailed wire and dilate toward SB4:Advance stent into the SBwith no MB protrusion and deploy the stentAssuming that the result is suboptimalBT stenting5:Perform final kissing inflation following advancement of a balloon in the MB.If needed us

30、e a new balloon for the SBCT stenting1:Wire both branches and predilate if needed2:Advance the 2 stents.MB stent positioned proximally.The SB stent will protrude only minimally into MBCrush stentingA3:Deploy the SB stent4:Check for optimal result in the SB and then remove balloon and wire from SB.De

31、ploy the MB stent BCrush stenting5:Rewire the SB and perform high pressure dilatation6:Perform kissing balloon inflationCCrush stenting1:Wire both branches and predilate if needed2:Remove from or leave the wire in the more straight branch(MB)and deploy a stent in the more angulated branch(SB)Culotte

32、 stentingA3:Remove the wire from the stented branch and cross with a wire and balloon into the of the unstented branch and dilate(MB).4:Place a second stent into the unstented branch(MB)and expand the stent leaving some proximal overlapBCulotte stenting5:Cross with a wire the first stent(SB)and perf

33、orm kissing balloon inflation.CCulotte stenting1:Wire both branches and predilate if needed2:Leave a wire in the SB and deploy a stent in the MB.Reverse crush stentingA3:Rewire side branch and advance a balloon and dilate toward SB4:Position a stent in the SB with minimal protrusion in the MB.Leave a balloon in the MBEVALUATE RESULT:if the result is not acceptable thenBReverse crush stenting5:Depl