Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,冠脉分叉病变不同介入治疗策略评价,阜外心血管病医院,杨伟宪,2010-7-24,2010-7,冠脉分叉病变不同介入治疗策略评价阜外心血管病医院,1,Account for 15-20%of PCI,Why an indivdualized approach?,Variations in Anatomy,Left main bifurcation disease,Plaque burden&location of plaque,Angle between MB and SB,Dynamic changes in anatomy during treatment,Plaque shift,Dissection,No two bifurcations are identical,An appropriate strategy from the outset saves time and minimizes complication,Bifurcation PCI,Account for 15-20%of PCIBifur,2,分叉病变分型,Duke Classification,Sanborn Classification,Iakovou I,Ge L,Colombo A.JACC,2005;46:1446-1455.,分叉病变分型Duke ClassificationSanbo,3,Safian Classification,Iakovou I,Ge L,Colombo A.JACC,2005;46:1446-1455.,Safian ClassificationIakovou I,4,Lefevre Classification,Iakovou I,Ge L,Colombo A.JACC,2005;46:1446-1455.,Lefevre ClassificationIakovou,5,Medina Classification,Medina et al.Rev Esp Cardiol.2006;59(2):183-4.,Medina ClassificationMedina et,6,分叉病变介入治疗策略,单支架,二个支架,分叉病变介入治疗策略单支架 二个支架,7,单个支架或二个支架?,A)如果分支血管的开口部位或其附近有明显的病变，其血管直径足够大，从安全性和PCI的疗效来考虑应该置入两个支架。,B),在其他情况下，应置入一个支架 and then evaluate,当前，大家公认和使用的分叉病变治疗策略是分支血,管 Provisional支架术。,然而仍有许多分支血管其解剖结构（直径较大，病变较为弥漫）需要置入两个支架。,单个支架或二个支架?A)如果分支血管的开口部位或其附近有明,8,What Type of Bifurcations are Commonly Treated?,Majority(65%)are“True”bifurcations,Extent of SB disease may determine strategy,Non-LM Bifs treated in Milan(n=320).Extent of SB disease:,0 18%,10mm 36%,What Type of Bifurcations are,9,分叉病变介入治疗技术,分支血管通畅技术,(KIO),必要时置入第二个支架（,Provisional 2,nd,stent）,双支架术,分叉病变介入治疗技术分支血管通畅技术(KIO),10,分支血管通畅技术,(KIO),当分支血管开口病变或弥漫性病变，并且分支血管不适合置入支架时（太细小）或者分支血管和临床症状不相关时,主支和分支血管分别放入导引钢丝,如果需要扩张主支血管,主支血管置入支架，分支血管保留导引钢丝,后扩张主支血管，分支血管保留受压的导引钢丝,不要再次把导引钢丝放入分支血管或者后扩张或预扩张分支血管,分支血管通畅技术(KIO)当分支血管开口病变或弥漫性病变，,11,Provisional,支架,当分支血管病变程度极轻或者病变仅位于分支血管开口处并且分支血管解剖结构适合置入支架者,主支和分支血管放入导引钢丝,扩张主支血管，必要时扩张分支血管,主支血管置入支架，分支血管保留导引钢丝,分支血管再次放入导引钢丝，然后撤出受压的原导,引钢丝,球囊对吻,如果分支血管出现次佳结果则在分支血管置入支,架（,T,支架术或,Reverse Crush,）,Provisional 支架当分支血管病变程度极轻或者病,12,保护分支血管,术前冠脉造影,前降支对角支病变,前降支置入支架,Xience 3.0 x28mm,保护分支血管术前冠脉造影前降支对角支病变前降支置入支架Xi,13,支架术后,对角支,POBA,球囊,3.0 x20mm,前降支对角支病,变,支架术后对角支POBA球囊3.0 x20mm前降支对角支病变,14,最终结果,最终结果,15,Wire both branches and pre,-,dilate the main and the side branch as required.,Step 1:,Stent the MB jailing the SB wire,If the result in SB unsatisfactory due to plaque shift or dissection and SB has to be stented,then re-cross into the SB through the MB stent struts,Step 2:,The T-stenting with Protrusion Technique(,TAP,),as a Cross-over from the Provisional Approach,Wire both branches and pre-dil,16,Position stent in SB ensuring coverage of ostium with minimal protrusion into MB and place non-compliant balloon in MB stent,Final Result:,Inflate the delivery balloon in the SB and the MB balloon simultaneously,Step 3:,Step 4:,The T-stenting with Protrusion Technique(TAP),as a Cross-over from the Provisional Approach,Position stent in SB ensuring,17,1,:Rewire side branch and advance a balloon and dilate toward SB,2,:Position a stent in the SB with minimal protrusion in the MB.Leave a balloon in the MB,EVALUATE RESULT:,if the result is not acceptable then,A,Reverse Crush,Stenting,1:Rewire side branch and adva,18,3,:Deploy the stent in the SB and remove the wire and the balloon,4,:Crush the short protruding part of SB stent over the stent in MB by inflating the MB balloon,B,Reverse Crush Stenting,3:Deploy the stent in the SB,19,5,:Rewire the SB and perform high pressure dilatation,6,:Perform final kissing balloon inflation,C,Reverse Crush Stenting,5:Rewire the SB and perform,双支架术,当分支血管的病变比较弥漫，不仅仅局限于分支开口部位，并且分支血管适合置入支架,主支和分支血管放入导引钢丝,扩张主支血管，必要时扩张分支血管,Crush,支架术或其他双支架术,如果进行,Crush:,分支血管再次放入导引钢丝,对其进行高压球囊扩张,球囊对吻扩张,双支架术当分支血管的病变比较弥漫，不仅仅局限于分支开口部位，,21,Crush,支架术,标准,Crush,：,7F,以上指引导管,事先对两个支架定位，然后释放分支血管支架，主支血管支架挤压分支血管支架,Reverse,（Internal）,Crush,：,行,P,rovisional,支架术时需要在分支血管置入另一个支架时采用。,6F,指引导管，首先释放主支血管支架，通过主支支架的侧孔置入分支血管支架，通过预留在主支的球囊对分支血管支架进行挤压,Inver,se,Crush,：,操作过程类似标准,Crush支架术，但是分支血管的支架定位比主支血管更为近端，分支血管的支架去挤压主支血管支架,Step Crush,：,与标准,Crush,技术相同，但可在,6F指引导管进行,Crush支架术标准Crush：7F以上指引导管,事先对两,22,Stenting Techniques for the Treatment Bifurcation Lesions,Louvard Y,Lefevre T,Morice MC,et al,Heart 2004;90:713-22,Classic T beginning SB,Modified T,Crush,Classic T,beginning MB,Provision T,Cullotte,Touching stents,Trouser legs and seat,Kissing stents,Skirt technique,Stenting Techniques for the Tr,23,分叉病变包括左主干病变的治疗方法,真性分叉病变,(,主支和分支血管明显狭窄,),非,是,主支血管置入支架，分支血管进行球囊扩张,分支血管适合支架术,分支血管病变，从开口向远端弥漫超过,3mm,以上,选择性置入两个支架（主支和分支）,分支血管,Provisional,支架术,分支血管,Provisional,支架术或,KIO,非,是,非,是,分叉病变包括左主干病变的治疗方法真性分叉病变非 是主支血管置,24,绝大多数分叉病变在介入治疗结束时需要保持分支血管通畅，残余狭窄似乎意义不大,如果分支血管达到最佳结果比较重要，在真性分叉病变中至少有,50,的患者需要置入两个支架,分叉病变总结,1 支架策略,只有临床需要才进行冠脉造影随访,绝大多数分叉病变在介入治疗结束时需要保持分支血管通畅，残余狭,25,BMS era:One stent is