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1、慢性完全闭塞病变介入技巧和器械选择北京安贞医院吕树铮 教授慢性完全闭塞病变介入技巧和器械选择l慢性完全闭塞病变的相关概念l慢性完全闭塞病变的病理结构和特点lCTO介入的导丝选择lCTO病变的支架选择CTO的定义l闭塞时间大于3个月的病变CTO病变形成时间的判断lAMI的时间l症状加重的时间l侧枝循环形成的多少及侧枝的直径CTO病变长度的判断l顺行显影l逆行显影l双向造影顺行显影逆行显影CTO病变的病理结构1. 坏死脂核、胆固醇结晶及钙化坏死脂核、胆固醇结晶及钙化CTO病变的病理结构2. 2. 细胞外基质：胶原、钙化细胞外基质：胶原、钙化CTO病变的病理结构3. 3. 微血管微血管CTO病变的类
2、型l重度狭窄慢性闭塞l轻中度狭窄慢性闭塞重度狭窄慢性闭塞主要由纤维化和钙化的粥样硬化斑块组成短闭塞段：纤维帽位于闭塞段的两侧边缘，中间为血管壁重塑形成的组织，闭塞时间一般为3个月以上，重塑的组织中含有大量的纤维组织长闭塞段：常常有血栓的成分，闭塞段往往是纤维组织与血栓相间分布。这种病变导丝很难通过，成功率只有5070%轻中度狭窄慢性闭塞脂核纤维组织陈旧血栓原有轻中度狭窄病变，班块破裂，未及时治疗，导致血管慢性闭塞，新的闭塞处远离原有狭窄斑块，导丝注意寻找闭塞斑块CTO病变的病理特点l粥样斑块+钙化慢性发展融合而成CTO病变的病理特点l斑块破溃形成血栓机化而成CTO介入的导丝选择导丝的结构导引导
3、丝的性能调节力：导丝尖端和中心钢丝结构柔软性：导丝的直径、尖端结构和连接段变系程度推送力：中心钢丝的硬度和中间变细方式支持力：中心钢丝的直径和材料处理CTO病变时常用的导丝l超滑导丝：如PT Graphic Intermediate、PT2、 Shinobi 、 Cross NT、Whisper等lCoil型导丝：ACS Intermediate Standard、Cross IT100-400、Miracle3-12及Conquest (Pro)9-12等处理CTO病变时常用导丝l超滑导丝The combination of a polymer cover and hydrophilic c
4、oating provides outstanding lubricity.SCIMED PT Graphic Intermediate Uni-body core with long, smooth taper from support region to tip Hydrophilic-coated, polymer sleeve and tip Intermediate wire with slightly stiffer tip Crossing performance of polymer tip with visibility of spring tipTerumo CrossNT
5、WHISPER Redefines Polymer Wire PerformanceResponsEase grind technologyDURASTEEL core materialPolymer Coated/Hydrocoat Distal segmentSoft tip designed for frontline useHI-TORQUE PILOT Design.007” Corewire SupportPTFE 喷涂喷涂 近端近端 黑色的黑色的PTFE 袖套延伸至远端头部袖套延伸至远端头部平的显影线圈平的显影线圈Shinobi & Shinobi Plus.010” Corew
6、ire supportSHINOBI PlusSHINOBIWIZDOM 的核心的核心钢丝钢丝STABILIZER Plus 的核心的核心钢丝钢丝处理CTO病变时常用的导丝lCoil型导丝 ACS Intermediate & Standard Intermediate：中软缠绕头端，core-to-tip，锥行渐变的中间轴 Standard：标准缠绕头端，不易扭曲的推送杆Cross IT100-400Smooth Shaft with Fluororesin coating Jointless Spring Coil Property of ASAHI NEOS PTCA GUIDEWIRE
7、 Family With the uni body core which is precisely tapered up to the extreme end, without additional ribbon, thus highly good torqueability is achieved.Shaft has fluororesin coating, which provides high operativity and good matching with balloon catheter.One Piece Core WireJointless spring coil made
8、of two different metals provides good torqueability and excellent slide property with devicesMedical Grade Silicone Coating（Tip load 3.0G）Miracle4.5 / Miraclebros4.5AG14M045Radio-opacity 11cmCoil 11 cmDiameter 0.014inchLength175cmFlexibilitySupportMoreMoreLess（Tip load 4.5G）Miracle6 / Miraclebros6AG
9、14M060Radio-opacity 11cmCoil 11 cmDiameter 0.014inchLength175cmFlexibilitySupportMoreMoreLess（Tip load 6.0G）Miracle12 / Miraclebros12AG14M070Radio-opacity 11cmCoil 11cmDiameter 0.014inchLength175cmFlexibilitySupportMoreMoreLow（Tip load 12.0G）Miracle3 / Miraclebros3AG14M050Radio-opacity 11cmCoil 11cm
10、Diameter 0.014inchLength175cmMiracle Series Applying the structure which further improves torque performance for CTO use.The tip part has the structure which is difficult to be trapped by the lesions.FlexibilitySupportMoreMoreLessStructure of Conquest Pro/Pro12 0.014”200mm Radiopaque Spring Coil0.00
11、9”Stainless Core WirePTFE CoatingHydrophilic CoatingAGH143090 Conquest ProGrand Slam / Grand Slam AG141002Radio-opacity 4cmCoil 4cmDiameter 0.014inchLength175cmFlexibilitySupportMoreMoreLessIn spite of its flexible tip, the core is also designed to provide strong support when approaching the tortuou
12、s lesions. （Tip load 0.7G）Marker WireAG141010Radio-opacity 3cmCoil 30cmDiameter 0.014inchLength175cmFlexibilitySupportMoreMoreLessSame level of tip stiffness as SOFT. It has ten markers starting after 50 mm from the tip to scale lesions and position devices. （Tip load 0.7G）Rinato / ProwaterAG146000R
13、adio-opacity 3cmCoil 20cmDiameter 0.014inchLength175cmCONQUEST / ConfianzaAG143090Radio-opacity 20cmCoil 20 cmDiameter 0.014inchLength175cmThis wire is developed for CTO use. Higher penetration ability than Miracles. Diameter of tip coil is tapered to 0.009 inch (0.23 mm). （Tip load 9.0G）Flexibility
14、SupportMoreMoreLessHydrophilic coating over the coil spring (after 3cm from the tip). Newly designed original core shaft gives adequately higher support performance than SOFT, improved torque performance. （Tip load 0.8G）FlexibilitySupportMoreMoreLess如何选择导丝 下列情况首选超滑涂层的导丝1. 闭塞段近端无边支开口，病变长度20mml4. 闭塞时间
15、6个月导丝通过闭塞段时的情况导丝通过闭塞段时的情况l1. 导丝通过闭塞1-6个月内、长度20mm没有钙化的病变时较顺利，成功率高。导丝通过闭塞段时的情况导丝通过闭塞段时的情况l2. 导丝通过有硬核的闭塞段时导丝无法穿透斑块，其尖端沿斑块边缘穿透血管壁导丝强行穿过硬斑块核如何判断导丝是否在真腔l1. 根据不同的投照角度如何判断导丝是否在真腔l2. 根据导丝尖端的形态和走性 真腔中导丝尖端弯形“J”存在，导丝可自由旋转，可沿主支血管走形前进，也能进入相应分支，并每次均能规律进入同一走行分支。如何判断导丝是否在真腔l3. 通过侧支循环显示闭塞段远端 造影通过逆行或顺行侧支显示闭塞段远端，多角度透射观
16、察导丝是否在真腔；在导丝即将通过闭塞段进入闭塞段远端血管真腔时尤应谨慎，导丝每前进1-2mm就应多角度投照，调整导丝尖端方向，防止损伤闭塞段远端血管，造成长夹层而不可修复。如何判断导丝是否在真腔l4. 通过OTW球囊造影判断 一旦导丝在假腔，造影时造影剂冲击损伤血管内膜，形成全程长夹层，导丝无法在进真腔，并造成远端血管闭塞心梗。 此法很少用.导丝成形及操作技巧CTO病变导丝尖端成形半径要小l成形半径大，则前向力被分解，导丝不易前行l成形半径大，对血管壁损伤大l成形半径大，不易调整方向闭塞段近端成角大的病变l要先将导丝头端塑形成较大的角度，使其易于通过闭塞段近端的扭曲，并将微导管或OTW球囊导入
17、到病变处；再将导丝重新塑形成小角度或换用塑形成小角度硬导丝，尝试通过病变。闭塞段较硬的病变l对于较硬的病变估计球囊不易通过者，除在导丝头端塑形成角后，可在导丝尖端再塑形第二个小角（只适用于Cross IT300-400、Conquest Pro9-12及Miracle9-12），将闭塞病变“掏”大，但导丝旋转速度不能快。CTO病变的支架选择CTO病变中PTCA和支架植入术比较：再狭窄发生率CTO病变中PTCA和支架植入术比较：再闭塞发生率l相对于单纯PTCA术，金属裸支架降低了再狭窄和再闭塞率，但仍然比较高l与金属裸支架相比雷帕霉素药物支架明显降低了低或中危再狭窄风险病人的晚期管腔丢失和再狭窄
18、率 CTO中应用CYPHER stent 的经验Hoye A., et al., J Am Coll Cardiol 2004;43(11):1954-8. -56例CYPHER治疗Ge L., et al.,Eur Heart J 2005:26(11):1056-62 -122例CYPHER治疗Nakamura S., et al., Am J Cardiol 2005;95:161-6 - 60例CYPHER治疗The SICTO StudyCYPHERTM Sirolimus-eluting stent in Chronic Total OcclusionThe PRISON II S
19、tudyPrimary Stenting of Occluded Native Coronary Arteries SICTO STUDY DESIGNA multicenter, prospective, non-randomized study to assess the feasibility and restenosis/reocclusion rates of coronary stenting with the CypherTM Sirolimus-eluting stent in patients with chronic total occlusion- 25 patients
20、 were treated with the CypherTM Sirolimus-eluting stent after successful balloon angioplasty and IVUS examination. - Clinical follow-up at 30 days, 6, 12, 18 and 24 months - repeat angiography and IVUS at 6 months follow-up. SICTO ConclusionIn this feasibility study the CYPHERTM Sirolimus-eluting st
21、ent was very effective in the treatment of CTO, with very low rates of TLR (0%), MACE (0%) and TVR (8%) compared to historical data with bare stents (30-50%).The CYPHERTM Sirolimus-eluting stent significantly inhibits intimal hyperplasia in CTO. These preliminary data will come in addition of larger
22、 database with CTO subpopulation (e.g. e-Cypher) PRISON II Study To compare the immediate and long-term angiographicand clinical results of BMS (Bx Velocity) implantationwith Sirolimus-eluting Stent (CYPHER) implantation forthe treatment of CTO 6-month Clinical Follow-upClinical Event (%)204P0.00124
23、8228194320P=0.003P=0.009P=0.001P=NSP=NS06-month Angiographic Follow-up In-StentBMS (n=94)SES (n=94)p valueRef. diameter (mm)3.01 0.853.44 0.540.0001MLD (mm)1.47 0.832.48 0.800.0001% diam. stenosis48.75 26.5222.01 20.980.0001Late Loss (mm)1.09 0.910.05 0.810.0001Net gain (mm)1.30 0.882.33 0.850.0001L
24、oss index0.45 0.37-0.02 0.410.0001 P0.0001 P0.0001P0.0001P0.00014136117%73%81%Angiographic Binary Restenosis Relative Risk ReductionConclusionsAs compared with bare metal stents, the CYPHER sirolimus-eluting stent implantation in CTO is superior with a significant reduction in binary in-segment and in-stent restenosisAs a consequence this resulted in a significant reduction of TLR and TVRA low rate of sub-acute and late stent thrombosis was observed in both groupsPRISON IIThanks Q&A
