复杂冠脉分叉病变的PCI治疗策略.ppt
PCI Strategies for Complex PCI Strategies for Complex Coronary Coronary Bifurcation lesionsBifurcation lesionsNordic Bifurcation Study(n=413)413 pts with bifurcation lesion Stenting of the main vessel and side branch(MV+SB)Stenting of the main vessel and optional stenting of the side branch(MV)n=206n=207RandomizedPresented at ACC 2006Nordic Bifurcation Study(n=413)Presented at ACC 2006Nordic Bifurcation Study(n=413)Provisional T StentProvision-T stent technique53 pts,SB2mmMACE 9.4%at 14+/-3 monthsTLR 3.8%,MV restensosis 3.2%,SB 12.9%at 6 monthsVigna C,et al.J Invasive Cardiol.2007 Mar;19(3):92-7.p The SB has a narrowing at its ostiump The MB has severe stenosis with a large plaqueburden and the SB originates with an angle of 45p The ostium of the SB deteriorates after pre-dilatation of the MBA wire is needed in the following circumstances:FKB is Very Important for Provisional T StentBMS EraDES EraT stent TechniqueCulotte TechniqueClinical OutcomesCulotte vs T stent in DES era80 patients with bifurcation lesions Culotte technique 45 cases T stent 35 casesThe procedural success rate 100%TLR:8.9%P=0.014;9monthsMACE 13.3%P=0.051Kaplan S,et al.Am Heart J.2007 Aug;154(2):336-43 The procedural success rate 100%TLR:27.3%9monthsMACE 27.3%SKS Technique200 patients with bifurcation lesions SKS technique Cypher stentsThe clinical success rate is 97%The incidence of TLR:4%9+/-2 monthsSharma SK.Catheterization and Cardiovascular Interventions 2005;65:1036 patients with bifurcation lesions SKS technique SES stents 26.7+/-8.6 monthThe 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 TechniqueCrush TechniqueClinical Outcomes7.1%12.5%5.5%35.0%0%10%20%30%40%主支主支边支边支对吻组非对吻组P=0.11Colombo et al.PCR 2004Final Kissing is very important!Step 1:Wire both branches and predilate bothStep 2:Both stents in place.Side-branch stent positioned more proximalInverted CrushWire both branches and predilateDeploy stent in main branchReverse crushing techniqueWire side branch and dilatePosition stent in side branch protruding in MB(slight),leave a balloon in MBDeploy stent in the side branch and remove wire and balloonCrush the protruding part of SB on top of the stent in MBBalloon CrushDK Crush(Sleeve Technique)mini-crush45 pts,52lesionsProcedural success 100%No in-hospital MACETLR 12.2%,MV restensosis 12.2%,SB 2%at 8 monthsGalassi AR,et al.Catheter Cardiovasc Interv.2007 1;69(7):976-83 TAP techniqueWire both branches and predilateDeploy stent in main branchWire side branch and dilateKissing balloonSB stent positioningSB stent is deployed with theuninflated balloon into the MVThe balloon of the SB stent is slightly retrieved and aligned to the MV balloonFinal kissing balloonPerfect coverage of the bifurcation withminimal stents struts overlap at the proximal part of SB ostium0.070”0.0710.078”6F7F 5.3F 5.4F 5.9F Size of Guiding Catheter MV balloon shaft profile+SB stent shaft profile 8F6.0F0.088”6 F 7 F 8 FGC5.4F0.0705.3F6F导管完成对吻扩张导管完成对吻扩张6F导引导管的内径：导引导管的内径：0.0700.071)两球囊推送杆两球囊推送杆外径之和外径之和应应5.3F6F导引导管进行球囊对吻技术导引导管进行球囊对吻技术选用选用导引导管：导引导管：6F JL 3.56F EBU 3.5BMW BMW 3.024mm CypherDeployment MV stent with jailed guidewire into the SBKissing balloon after rewiring of SBSB stent positioningSB stentMV balloonThe position of the SB stent is adjusted to fully cover the proximal part of the SB ostium(red arrow)while an uninflated balloon kept into the MV SB is deployed with the uninflated balloon into MVSB stent deploymentThe balloon of the SB stent is slightly retrieved and aligned to the MV balloonFinal kissing balloon SB stents balloon MV balloonFinal Result Burzotta F,et al.Catheterization and Cardiovascular Interventions 2007,70:7582Procedure characteristics Strategies for LMCA lesionsStent implantation in the side branch?NoYes6F Guiding Catheter Treatment StrategyBalloon/DK/Reverse crushProvisional T stent/CulotteStandard crush/SKSModified T stent6F Guiding Catheter7F Guiding Catheter116 pts with LMCA bifurcation lesions Cross-over (n=67)Complex strategy (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 easier and appeared to be more effective in improving long-term outcomes for lesions with normal or diminutive LCXConclusion
