分叉病变的介入治疗候静波教授.pdf

分叉病变的介入治疗候静波教授.pdf

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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66年年,加重加重11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22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年年1010月），月），1010年年66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过程紧急于前降紧急于前降支植入支植入22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，Pilot150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provisionalT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:

Bifurcationlesions15-20%oflesionstreatedinthecathlabStillachallengeforinterventionalistsLowersuccessratesHigherincidenceofproceduralcomplicationsHigherreinterventionratesIdealstrategyofbifurcationlesiontreatmentisstilldebatedBifurcationClassification（Medinaetal）Classification1or2Stents:

RandomizedTrialsStudyNo.Pat-ientsTwo-stentStrategyTypeofDESThienopyridineduration,moIntentiontoTreatAngioF/U（months）ClincialF/U（months）Panetal91AnySES12Yes611Colomboetal85AnySES3No66NORDIC413AnySES6-12Yes86Ferencetal.202T-stentingSES6-12Yes912,24BBCONE500CrushorCulottePES9Yes9CACTUS350CrushSES6Yes66,12Braretal.EuroIntervention,2009（in-press）BifurcationStentingMeta-Analysis1101000.10.01MortalityPanetalColomboetalNORDICFerencetal.BBCONECACTUSOverallFavorsProvisionalFavorsTwo-StentRelativeRisk（95%CI）1.12（0.42-3.02）P=0.820.9%Provisional0.7%TwoStentBraretal.EuroIntervention,2009（in-press）BifurcationStentingMeta-Analysis1101000.10.01MyocardialInfarctionPanetalColomboetalNORDICFerencetal.BBCONECACTUSOverallFavorsProvisionalFavorsTwo-StentRelativeRisk（95%CI）0.57（0.37-0.87）P=0.013.6%Provisional6.8%TwoStentReduction43%Braretal.EuroIntervention,2009（in-press）BifurcationStentingMeta-Analysis1101000.10.01TargetLesionRevascularizationPanetalColomboetalNORDICFerencetal.BBCONECACTUSOverallFavorsProvisionalFavorsTwo-StentRelativeRisk（95%CI）0.91（0.61-1.35）P=0.635.1%Provisional5.4%TwoStentBraretal.EuroIntervention,2009（in-press）BifurcationStentingMeta-Analysis1101000.10.01MainBranchStenosisPanetalColomboetalNORDICFerencetal.CACTUSOverallFavorsProvisionalFavorsTwo-StentRelativeRisk（95%CI）1.41（0.76-2.61）P=0.274.9%Provisional3.6%TwoStentBraretal.EuroIntervention,2009（in-press）BifurcationStentingMeta-Analysis1101000.10.01SideBranchStenosisPanetalColomboetalNORDICFerencetal.CACTUSOverallFavorsProvisionalFavorsTwo-StentRelativeRisk（95%CI）1.09（0.79-1.51）P=0.6014.0%Provisional13.3%TwoStentBraretal.EuroIntervention,2009（in-press）BifurcationStentingMeta-Analysis1101000.10.01StentThrombosisPanetalColomboetalNORDICFerencetal.BBCONECACTUSOverallFavorsProvisionalFavorsTwo-StentRelativeRisk（95%CI）0.56（0.23-1.51）P=0.450.8%Provisional1.7%TwoStentBraretal.EuroIntervention,2009（in-press）FavorsProvisionalBifurcationStentingMeta-Analysis11020-10-20QCAAnalysisPercentDiameterStenosis（differenceinmeans）PanetalColomboetalNORDICFerencetal.CACTUSOverallFavorsProvisionalFavorsTwo-Stent-1.08（-2.91-0.74）Braretal.EuroIntervention,2009（in-press）11020-10-20PanetalColomboetalNORDICFerencetal.CACTUSOverallFavorsTwo-Stent1.30（-23.35-5.96）MainBranchSideBranch没有过多的分叉处病变没有过多的分叉处病变ThereisnotoomuchBifurcationlesion.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%NORDICBBKCACTUSBBCONECrossoverfrom1stentto2stentsAngiographicSBrestenosisHowOftenWeNeed2ndStentafterMVStent?

Crossoverfrom1Stentto2StentsSteigenTKetal.Circulation.2006;114:

1955-1961FerencMetal.EurHeartJ2008;29:

28592867ColomboAetal.Circulation.2009;119:

7178Hildick-SmithDetal.Circulation.2010;121:

1235-1243TVFduetoSBrestenosis2.8%（noangiof-up）NAINSIDEIITrialPtsRandomizedto1Stent:

PredictorsofCross-OvertoSBStentingVARIABLEYESNOPvalueQCALesionlength,mm13.98.870.01Referencediameter2.472.510.83%DS88.671.70.02IVUSMLA,mm21.732.330.005Plaqueburden65.559.10.41Remodelingindex0.650.960.03Calcium（arc90O）,%83.329.30.006UnfavourableangleUnfavourableangleUnfavourableangle:

minicrushFinalTrueBifurcation（significantstenosisonthemainandsidebranches）NoYesStentonMB“KeepItOpen”forSBIsSBsuitableforstenting?

SBdiseaseisdiffuse&/ornotlocalizedtowithin3mmfromtheostium?

ProvisionalSBstentingElectiveimplantationoftwostents（MBandSB）ProvisionalSBstentingYesYesNoNoCorrelationBetweenFFRand%Stenosis（QCA）inJailedSideBranchesTherewasanegativecorrelationbetweenthepercentstenosisandFFR（r=0.41,p0.001）.Nolesionwith75%stenosishadFFR1mmassociatedwith14%incidenceofMyocardialInfarctionAroraRRetal.CathetCardiovascDiagn1989;18:

210-2.SBclosureassociatedwithlargeperiproceduralMIChaudhryECetal.JThrombThrombolysis2007.WhyProtectSBsfromClosure?

WhentheSBhasostialordiffusediseaseANDwhentheSBisnotsuitable（toosmall）forstentingorclinicallynotrelevant6Frguidingcatheter1.Wirebothbranches2.DilateMBifneeded3.StentMBandleavewireintheSB4.Post-dilatationofMBwithjailedwireinSBKeepItOpen（KIO）Donotre-wireSBorpostdilateorpredilateSBWhenSBhasminimaldiseaseoronlyattheostiumANDwhenSBissuitableforstenting6Fror7Fguidingcatheter1.Wirebothbranches2.DilateMBandSBifneeded3.StentMBleavingawireintheSBRe-wireSBandthenremovejailedwire（Prowater/Rinato,BMW,Runthrough,intermediatewire,Pilot50or150,feilderwire）KissingballooninflationStentSBonlyifsuboptimalresult（TAP,reversecrush,culotte）ProvisionalWhenSBhasdiseaseextendingbeyonditsostiumANDwhenSBissuitableforstenting7Frguidingcatheter1.Wirebothbranches2.DilateMBandSBifneeded3.Performcrush,culotteorV-stent4.Ifcrush:

rewireSBandperformhighpressureSBdilatation（2-stepkiss）5.Finalkissingballooninflationalways!

TwoStents2-StepKissNoKissOne-stepKissTwo-stepKissABCSlidecourtesyofJohnOrmistonOptimalPerformanceof2StentTechniquesImportantinReducingEventRatesImpactoflearningcurveinTechnique;TCT2006BifurcationallesionwithnodiseaseproximaltothebifurcationorveryshortleftmainBifurcationallesionwithmainbranchdiseaseextendingproximaltothebifurcationandsidebranchwhichhasoriginwithabout90angleBifurcationallesionwithmainbranchdiseaseextendingproximaltothebifurcationandsidebranchwhichhaoriginwithabout60angleV-StentT-StentShort-MiniCrushCrossSectionPrePostPrePostPrePostAnapproachforbifurcationallesionswhenusing2stentsasintentiontotreatTheT-stentingwithProtrusionTechnique（TAP）asaCross-overfromtheProvisionalApproachWirebothbranchesandpre-dilatethemainandthesidebranchasrequired.Step1:

StenttheMBjailingtheSBwireIftheresultinSBunsatisfactoryduetoplaqueshiftordissectionandSBhastobestented,thenre-crossintotheSBthroughtheMBstentstrutsStep2:

PositionstentinSBensuringcoverageofostiumwithminimalprotrusionintoMBandplacenon-compliantballooninMBstentFinalResult:

InflatethedeliveryballoonintheSBandtheMBballoonsimultaneouslyStep3:

Step4:

TheT-stentingwithProtrusionTechnique（TAP）asaCross-overfromtheProvisionalApproach1:

Wirebothbranchesandpredilateifneeded2:

StenttheMBleavingawireintheSB.ThestentintheMBcanbedeployedathighpressureTstentingA3:

RewiretheSBpassingthroughthestrutsoftheMBstent,removethejailedwireanddilatetowardSB4:

AdvancestentintotheSBwithnoMBprotrusionanddeploythestentAssumingthattheresultissuboptimalBTstenting5:

PerformfinalkissinginflationfollowingadvancementofaballoonintheMB.IfneededuseanewballoonfortheSBCTstenting1:

Wirebothbranchesandpredilateifneeded2:

Advancethe2stents.MBstentpositionedproximally.TheSBstentwillprotrudeonlyminimallyintoMBCrushstentingA3:

DeploytheSBstent4:

CheckforoptimalresultintheSBandthenremoveballoonandwirefromSB.DeploytheMBstentBCrushstenting5:

RewiretheSBandperformhighpressuredilatation6:

PerformkissingballooninflationCCrushstenting1:

Wirebothbranchesandpredilateifneeded2:

Removefromorleavethewireinthemorestraightbranch（MB）anddeployastentinthemoreangulatedbranch（SB）CulottestentingA3:

Removethewirefromthestentedbranchandcrosswithawireandballoonintotheoftheunstentedbranchanddilate（MB）.4:

Placeasecondstentintotheunstentedbranch（MB）andexpandthestentleavingsomeproximaloverlapBCulottestenting5:

Crosswithawirethefirststent（SB）andperformkissingballooninflation.CCulottestenting1:

Wirebothbranchesandpredilateifneeded2:

LeaveawireintheSBanddeployastentintheMB.ReversecrushstentingA3:

RewiresidebranchandadvanceaballoonanddilatetowardSB4:

PositionastentintheSBwithminimalprotrusionintheMB.LeaveaballoonintheMBEVALUATERESULT:

iftheresultisnotacceptablethenBReversecrushstenting5:

Depl