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1、*1*1Xijing Hospital Application of Percutaneous Coronary Intervention for Severe Calcification Lesions 严重钙化病变的PCI治疗王海昌第四军医大学西京医院心脏内科 陕西西安*2*2Xijing Hospital *3*3Xijing Hospital Culprit and Healed Plaques in a Coronary BifurcationCoronary artery disease : Diffuse disease with a variable mix of stable
2、 , vunerable and culprit plaques Fuster V, etal. JACC, 2005:46:937-954*4*4Xijing Hospital Epidemiology o由动脉粥样硬化导致，非退行性变o检出率存在显著的性别差异 （女：男=1： 2）o冠状动脉钙化计分随年龄增加呈增加趋势 o冠心病危险因素与冠状动脉钙化密切相关 oBakdash 等报告非脂质性冠状动脉危险因 素的数目与冠状动脉钙化沉积有关 *5*5Xijing Hospital 29% of men and 15% of women who had no cardiovascular sym
3、ptoms and exhibited no other common risk factors, had extensive coronary artery calcification. European Heart Journal 25: 4855, 2004 *6*6Xijing Hospital q Angiogram cannot detect calcifications (CAG)q Ultrafast computed tomography (CT scanning) q can measure arterial calcification (noninvasive)q Int
4、ravascular Ultrasound （IVUS）q Optical Coherence Tomography (OCT)Diagnosis Methods *7*7Xijing Hospital *8*8Xijing Hospital *9*9Xijing Hospital Calcified coronary plaques imaged in vivo by optical coherence tomography (OCT) and intravascular ultrasound (IVUS)OCTOCTIVUSIVUS*10*10Xijing Hospital Non-inv
5、asive Quantification for Calcified Lesions by CT Scan*11*11Xijing Hospital *12*12Xijing Hospital *13*13Xijing Hospital “中重度钙化（B型）病变是导致冠状动脉球囊成形术（PTCA）手术失败和血管急性闭塞的主要危险因素” 1988年ACC/AHA心血管诊治技术评价的报告*14*14Xijing Hospital 钙化病变介入治疗q 单纯球囊扩张（PTCA）q 成功率低（74），夹层率高，急性血管闭塞率高q 球囊扩张支架术 可改善球囊扩张后的效果，提高成功率 严重钙化病变，单凭高压
6、力植入支架，并发症高、再狭窄率高*15*15Xijing Hospital 钙化病变单纯PTCA的局限性q 即刻效果病变不能扩展和发生弹性回缩q 再狭窄多数研究没有显示钙化病变和PTCA后再狭窄之间的关系*16*16Xijing Hospital Case 1 ( Balloon + DES)CAG*17*17Xijing Hospital Case 1 ( Balloon + DES)COSTLY!p 3.5 hrs Operation time p Long X-Ray Exposure p 6 Balloons p 3 Guide Wire p 3 Drug Elution Stents
7、*18*18Xijing Hospital Case 1 ( Balloon + DES)Pre-O Final CAG*19*19Xijing Hospital 球囊成形术（PTCA）q 冠脉夹层 1.发生率高，程度重。 2.部位在钙化与非钙化斑块的移行处，与球囊扩张 过程中所产生的不均匀的剪切力有关 3.发生率从旋磨后的22增加到辅以球囊扩张后的 77，夹层分离的部位也从钙化斑块的内（旋磨后 ）移至钙化斑块的外（PTCA后） 4.高压扩张，增加了球囊破裂和夹层分离的危险。*20*20Xijing Hospital Initial Reaction :Fear *21*21Xijing Ho
8、spital Atherectomy remove the plaque itself, cutting the soft plaque from the obstruction site depositing it in a capsule which is then withdrawn.Atherocath courtesy Guidant*22*22Xijing Hospital LaserSome catheters have also been fitted with special lasers which can photo- dissolve the tissue obstru
9、cting the arteries. Laser catheter准分子激光冠脉成形术（ELCA） 有报道称手术成功率较高。使钙化破 裂而不是清除，对一些不能扩张的病 变是有效的。术后再狭窄率较高为 4050。已经被旋磨取代*23*23Xijing Hospital Rotablator : rotational atherectomy catheterRotablatorolive-shaped diamond burr rotates at extremely high speed*24*24Xijing Hospital Rotablator Syetem 驱动杆导丝钻石涂层磨头 1.
10、25 mm - 2.5 mm (0.25 mm increments)鞘管 4.3 french O.D.*25*25Xijing Hospital Rotablation is recommended for fibrotic or heavily calcified lesions that can be wired but not crossed by a balloon or adequately dilated before planned stenting. One must know how to manage the complications inherent to rota
11、blation. AHA/ACC/FDA PCI Guideline*26*26Xijing Hospital 钙化病变的分类q 内膜面钙化严重者影响球囊、支架的充分扩张，需要旋磨q 外膜或斑块基底部钙化造影显示明显，对PCI影响不大，不需旋磨*27*27Xijing Hospital DES时代钙化病变治疗的要点q 钙化病变预扩张 q 支架完全覆盖病变 q 支架释放压16-18ATM q 后扩张 q 血管内超声 *28*28Xijing Hospital STRTAS ( Study To Determine Rotablator and Transluminal Angioplasty S
12、trategy ) 初 步结果显示，采用更大的磨头和较长的旋磨时间 进行强烈的消蚀与更保守的消蚀方法相比，并没 有改善即刻和远期效果。旋磨支架（rotastent）能得到最大的管腔 和最小的残余狭窄。*29*29Xijing Hospital 钙化病变介入治疗的难点（I）q 单纯依靠冠脉造影评价钙化程度欠准确q 植入支架后的再狭窄率高q 旋磨术适于内膜弥漫钙化病变，利于支架充分 植入，长期疗效更好，“无复流现象”增加q 斑块切除术（DCA、TEC、ELCA）对钙化病变帮 助较小*30*30Xijing Hospital 钙化病变介入治疗的难点（II）q 直接支架植入应当慎重 支架通过困难，易造
13、成支架脱落率增加 如用高压力（16atm）仍未使支架充分扩张者，采用更高压力（ 20atm ），仍可能不会达到满意的支架扩张 支架不能充分扩张，亚急性血栓发生率增加 内膜夹层、撕裂率增加 球囊破裂、血管破裂、心包填塞增加*31*31Xijing Hospital Case2：Severe Calcification and Balloon Suboptimal Dilation lead to Acute Stent ThrombosisMale ，57yrs Smoking 30yrs， Chest pain 3yrs，Rest ECG：V1-V3 lead ST segment depre
14、ssion0.1m v Cadiac Triponin T(-)Severe Calcification Baloon dilation Stenting *32*32Xijing Hospital Case2：Severe Calcification and Baloon Suboptimal Dilation lead to Acute Stent Thrombosis4 days later!*33*33Xijing Hospital Female，76yrs Exertional chest pain 8yrs, recurrent 10days EF:40%RCA1:50， RCA3
15、:75LAD6：75,7段90 with severe calcification，8:50，9:50； LCX13:100 ,14:25%,15: 50Case3： Rotational Atherectomy for Severe Calcification *34*34Xijing Hospital Cutting Balloon: 2.5*10 (16ATM, 20“)Post dilate balloon: 2.513 (18ATM, 12“)Case3： Rotational Atherectomy for Severe Calcification *35*35Xijing Hos
16、pital Guiding ： 6F EBU3.5Guide Wire： Stablizer/ PT2MS Bur: 1.5mm Rotor rate ： 160000 rpmCase3： Rotational Atherectomy for Severe Calcification *36*36Xijing Hospital 2.524 TAXUS(10ATM, 8“) 2.7528 TAXUS(12ATM, 7“)Final CAG Stenting *37*37Xijing Hospital 钙化病变的器械选择（I）导引导管： 强支撑力导引导丝：亲水涂层导丝， 支撑力好， 采用微导管交换钢丝球囊和支架通过性好*38*38Xijing Hospital 钙化病变的器械选择（II）q 支架 建议选择设计有桥
