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1、分叉病变介入治疗分叉病变介入治疗天津市第三中心医院心脏中心天津市第三中心医院心脏中心 刘迎午刘迎午ContentnDefinition of bifurcation lesionnClassification of bifurcation lesionnStrategy of bifurcation-one stent or two stentsnSpecific stent for bifurcationnClinical casesdefinitionn累及到冠状动脉分叉的病变累及到冠状动脉分叉的病变n冠状动脉病变中分叉病变较为常见，约占经皮冠状冠状动脉病变中分叉病变较为常见，约占经皮冠状
2、动脉介入治疗动脉介入治疗(pereutaneous coronary (pereutaneous coronary interventionintervention，PCI)PCI)的的15152020n分叉病变的解剖结构分叉病变的解剖结构( (斑块负荷、斑块位置、血管角斑块负荷、斑块位置、血管角度、血管直径、分叉位置度、血管直径、分叉位置) )千变万化而治疗过程中千变万化而治疗过程中解剖结构也会随时改变解剖结构也会随时改变( (斑块迁移、血管夹层斑块迁移、血管夹层) ) n所以无两个完全一致的分叉病变，更无一种可适用所以无两个完全一致的分叉病变，更无一种可适用于所有分叉病变的手术方法于所有分
3、叉病变的手术方法ClassificationClassification of bifurcation lesions according to plaque burdenA:DukeB:SanbornC:SafianD:LefevreMedina A. et al. Rev Esp Cardiol. 2006; 59: 183-4A New Classification of Coronary Bifurcation Lesions- Medina Classification1, 1, 11 , 1, 01, 0 , 10, 1, 11, 0, 00, 1, 00, 0, 1MB Dist
4、alMB ProximalSBn一个好还是两个好？一个好还是两个好？n如果选个，应该采取何种策略如果选个，应该采取何种策略 ?n策略选择的根据策略选择的根据n 简单化简单化 vs 复杂化复杂化n 循证结果循证结果 vs 个人选择个人选择n 并发症率并发症率 (especially MI / thrombosis)分叉病变介入治疗分叉病变介入治疗- 关注热点关注热点 Stenting for bifurcation lesions in 2007主支放支架，分支临时决定主支放支架，分支临时决定Stenting the main vessel with provisional stenting o
5、f the side branch Provisional Stenting Strategyn If 2nd stent is needed for side branch following main vessel stentingn Modified T-stentingn Reverse crushingn Culotte stenting分支血管的保护与放置支架分支血管的保护与放置支架n 并非所有分支血管同等重要并非所有分支血管同等重要!n 根据以下情况实施分支血管保护和支架植入根据以下情况实施分支血管保护和支架植入n 分支血管大小与分布区域分支血管大小与分布区域n 分支血管开口病变
6、与病变程度分支血管开口病变与病变程度n 分支与主支成角程度分支与主支成角程度Side branch closure after PCISide-branch may be compromised following main vessel stentingPre-treatmentAfter stentingPlaque shifting(“Snow-plow”)Ostial spasm orSide-branch compromise by stent materialDissection of plaque at origin of side-branchDissection flap a
7、t main artery obstructing origin of side-branchAt times, the side branch could be compromised by thrombus tooDifferent techniques of two stents by intention to treat bifurcation lesionsnThe V stenting techniquenThe simultaneous kissing stents techniquenThe T stenting and modified T stenting techniqu
8、e nThe crush technique(The reverse crush technique/The step crush technique/The inverted crush technique)nThe culottes stenting techniquenThe Y stenting techniquenThe skirt techniqueThe V stenting techniqueThe simultaneous kissing stents techniqueThe V stenting and the simultaneous kissing stenting
9、techniquen适合于分叉病适合于分叉病变位于接近开口的血管近端，位于接近开口的血管近端，例如位于左主干的分叉病例如位于左主干的分叉病变，并且左主干，并且左主干短或无病短或无病变。理想。理想夹角角90。nV支架也适合于其他部位的分叉病支架也适合于其他部位的分叉病变，近，近段无病段无病变或无或无须支架。支架。 The V stenting and the simultaneous kissing stenting techniquen优点点:保保证不会不会丢失分支。失分支。 对吻技术时无须对吻技术时无须 re-cross any stent. The V stenting and the s
10、imultaneous kissing stenting techniquen缺点缺点:双支架近端定位双支架近端定位较困困难；不可避免造成其中一个支架偏心，往往引起不可避免造成其中一个支架偏心，往往引起 a gap。The T stenting techniqueThe modified T stenting techniqueThe T and modified T stenting techniquen优点点:较crush 技技术容易完成。容易完成。缺点缺点:大多数情况下，分支开口不能完全覆盖。大多数情况下，分支开口不能完全覆盖。Colombo et al Circulation 2004
11、; 109:1244-1249Colombo et al Circulation 2004; 109:1244-1249* High cross-over rate from Stent + Balloon to * High cross-over rate from Stent + Balloon to Stent + Stent group (22/43, 51%) Stent + Stent group (22/43, 51%)Cypher Cypher Bifurcation Bifurcation StentingStenting ( T-stenting ) ( T-stentin
12、g )Effects of the T stenting techniqueRESEARCH bifurcation subgroupRR of different techniquesThe high restenosis rate of T stenting technique may be related to the incomplete coverage of stenting being located at the ostium of SB.Tanabe K, Hoye A, Lemos PA, et al. Am J Cardiol, 2004, 91:115-8Effects
13、 of the T stenting techniqueV stenting vs T stentingnSharma et al.nV stenting:100nProvisional T stenting: 100n32% subjects received Cypher stent and RVD was 3.32mm。Provisional T stentingn优点点:Higher procedural success rateLower expenseLower complicationsLower re-PCIn7mons TLR 15%。nLefevre et al: Prov
14、isional T stenting is the golden standard to treat false bifurcation lesion(tpye2, 3 and 4a), most subjects only need one stent implantation。Provisional T stentingThe crush techniqueThe crush techniquen优点点:可以保可以保证两条分支的立刻开通两条分支的立刻开通,这点点对保保护功能上重要的功能上重要的分支非常重要。分支非常重要。可以完全覆盖分支开口。可以完全覆盖分支开口。n缺点缺点:由于有多由于有
15、多层支架金属，支架金属，导丝和球囊再次通和球囊再次通过较困困难，操作，操作复复杂。Ge et al. JACC 2005; 46: 613Long term outcome of “Crush”Stenting technique 6 mons RR Colombo et al. The crush techniqueThe reverse crush or internal crush techniqueThe reverse crush or internal crush techniquen主要用于主要用于临时分支支架植入分支支架植入provisional SB stenting. Th
16、e reverse crush or internal crush technique 优点点:可以保可以保证两条分支的立刻开通，两条分支的立刻开通，6F guiding catheter可以完成操作。可以完成操作。 缺点缺点:由于有多由于有多层支架金属，支架金属，导丝和球囊再次通和球囊再次通过较困困难，操作复操作复杂。The step crush techniqueCase: The step crush techniqueFirst kissingSecond kissingFinal resultThe step crush techniquen优点点:6F guiding cathet
17、er可以完成操作，特可以完成操作，特别适合于适合于桡动脉脉经路，第二次路，第二次导丝和球囊再次通和球囊再次通过较容易成功。容易成功。 缺点缺点:同同 the standard crush technique. The inverted crush techniqueThe inverted crush techniquen适用于分支管径不小于主支的情况。适用于分支管径不小于主支的情况。n分支支架分支支架挤压crush主支支架主支支架。n缺点缺点:同同 the standard crush technique. Restenosis in MV = 12.2%Restenosis in SB =
18、 2%Galassi et al. Cath & Cardiovas. Intervn 2007; 69: 976-83Galassi et al. Cath & Cardiovas. Intervn 2007; 69: 976-83The culottes stenting techniqueThe culottes stenting techniquen优点点:适合于任何角度的分叉病适合于任何角度的分叉病变，并提供完美的，并提供完美的分支开口覆盖。分支开口覆盖。n缺点缺点:分叉病分叉病变近段双近段双层支架重叠，金属密度高。支架重叠，金属密度高。Nordic Bifurcation Stud
19、y IINordic Bifurcation Study II- The Nordic Stent Technique Study- The Nordic Stent Technique Study: Crush vs Culotte stenting: Crush vs Culotte stentingNordic Bifurcation Study IINordic Bifurcation Study II- The Nordic Stent Technique Study- The Nordic Stent Technique Study: Crush vs Culotte stenti
20、ng: Crush vs Culotte stentingIndividual end-point at 6 months The Y stenting techniqueThe skirt techniqueThe Y stenting technique and The skirt techniquen优点点:这是最后一种治是最后一种治疗分叉病分叉病变的方法，适用于非常的方法，适用于非常复复杂的分叉病的分叉病变并要求保并要求保证导丝进入两分支。入两分支。n缺点缺点:n近端支架近端支架释放系放系统需要改良，手工将支架捻在双需要改良，手工将支架捻在双球囊上。球囊上。应用用DES易破坏易破坏po
21、lymer 。n近端支架很近端支架很难完全完全连接接远端双支架。端双支架。n采用采用Y 支架技术时，多数术者将分支导丝回撤并支架技术时，多数术者将分支导丝回撤并放入主支，这时释放近端支架可以更好放入主支，这时释放近端支架可以更好连接接远端端支架支架The Y stenting techniquen77 case being with bifurcation lesions received the Y stenting therapy and 6 mons follow-up results:RR 36%, TLR 30%。Maillard L, Guerin L, Drieu L, et a
22、l. Am J Cardiol 1998;82:7A50SClassification of bifurcation lesions according to plaque burdenA:DukeB:SanbornC:SafianD:LefevreoThe V stenting techniqueoThe simultaneous kissing stents techniqueoThe T stenting and modified T stenting technique oThe crush technique(The reverse crush technique/The step crush technique/The inverted crush technique)oThe culottes stenting techniqueEach lesion must be approached therapeutically in the context of its own anatomy.
