冠脈叉病變介入技巧ClassificationofbifurcationlesionsaccordingtoplaqueburdenA:DukeB:SanbornC:SafianD:Lefevre2冠脈叉病變介入技巧MedinaA.etal.RevEspCardiol.2006;59:183-4ANewClassificationofCoronaryBifurcationLesions-MedinaClassification1,1,11,1,01,0,10,1,11,0,00,1,00,0,1MBDistalMBProximalSB3冠脈叉病變介入技巧一個好還是兩個好？如果選２個，應(yīng)該采取何種策略?策略選擇的根據(jù)簡單化vs復(fù)雜化循證結(jié)果vs個人選擇并發(fā)癥率(especiallyMI/thrombosis)分叉病變介入治療

-關(guān)注熱點(diǎn)4冠脈叉病變介入技巧Stentingforbifurcationlesionsin2007主支放支架，分支臨時決定Stentingthemainvesselwithprovisionalstentingofthesidebranch5冠脈叉病變介入技巧ProvisionalStentingStrategy

If2ndstentisneededforsidebranchfollowingmainvesselstentingModifiedT-stentingReversecrushing Culottestenting 6冠脈叉病變介入技巧分支血管的保護(hù)與放置支架

并非所有分支血管同等重要!

根據(jù)以下情況實(shí)施分支血管保護(hù)和支架植入分支血管大小與分布區(qū)域分支血管開口病變與病變程度分支與主支成角程度7冠脈叉病變介入技巧SidebranchclosureafterPCI8冠脈叉病變介入技巧Side-branchmaybecompromisedfollowingmainvesselstentingPre-treatmentAfterstentingPlaqueshifting(“Snow-plow”)OstialspasmorSide-branchcompromisebystentmaterialDissectionofplaqueatoriginofside-branchDissectionflapatmainarteryobstructingoriginofside-branchAttimes,thesidebranchcouldbecompromisedbythrombustoo9冠脈叉病變介入技巧DifferenttechniquesoftwostentsbyintentiontotreatbifurcationlesionsTheVstentingtechniqueThesimultaneouskissingstentstechniqueTheTstentingandmodifiedTstentingtechniqueThecrushtechnique(Thereversecrushtechnique/Thestepcrushtechnique/Theinvertedcrushtechnique)TheculottesstentingtechniqueTheYstentingtechniqueTheskirttechnique10冠脈叉病變介入技巧TheVstentingtechnique11冠脈叉病變介入技巧Thesimultaneouskissingstentstechnique12冠脈叉病變介入技巧TheVstentingandthesimultaneouskissingstentingtechnique適合于分叉病變位于接近開口的血管近端，例如位于左主干的分叉病變，并且左主干短或無病變。理想夾角<90°。V支架也適合于其他部位的分叉病變，近段無病變或無須支架。

13冠脈叉病變介入技巧TheVstentingandthesimultaneouskissingstentingtechnique優(yōu)點(diǎn):保證不會丟失分支。

對吻技術(shù)時無須re-crossanystent.14冠脈叉病變介入技巧TheVstentingandthesimultaneouskissingstentingtechnique缺點(diǎn):雙支架近端定位較困難；不可避免造成其中一個支架偏心，往往引起agap。15冠脈叉病變介入技巧TheTstentingtechnique16冠脈叉病變介入技巧ThemodifiedTstentingtechnique17冠脈叉病變介入技巧TheTandmodifiedTstentingtechnique優(yōu)點(diǎn):較crush技術(shù)容易完成。缺點(diǎn):大多數(shù)情況下，分支開口不能完全覆蓋。18冠脈叉病變介入技巧ColomboetalCirculation2004;109:1244-1249*Highcross-overratefromStent+BalloontoStent+Stentgroup(22/43,51%)CypherBifurcationStenting(T-stenting)EffectsoftheTstentingtechnique19冠脈叉病變介入技巧RESEARCHbifurcationsubgroupRRofdifferenttechniquesThehighrestenosisrateofTstentingtechniquemayberelatedtotheincompletecoverageofstentingbeinglocatedattheostiumofSB.TanabeK,HoyeA,LemosPA,etal.AmJCardiol,2004,91:115-8EffectsoftheTstentingtechnique20冠脈叉病變介入技巧VstentingvsTstentingSharmaetal.Vstenting:100ProvisionalTstenting:10032%subjectsreceivedCypherstentandRVDwas3.32mm。21冠脈叉病變介入技巧ProvisionalTstenting22冠脈叉病變介入技巧優(yōu)點(diǎn):HigherproceduralsuccessrateLowerexpenseLowercomplicationsLowerre-PCI7monsTLR<15%。Lefevreetal:ProvisionalTstentingisthegoldenstandardtotreatfalsebifurcationlesion(tpye2,3and4a),mostsubjectsonlyneedonestentimplantation。ProvisionalTstenting23冠脈叉病變介入技巧Thecrushtechnique24冠脈叉病變介入技巧Thecrushtechnique優(yōu)點(diǎn):可以保證兩條分支的立刻開通,這點(diǎn)對保護(hù)功能上重要的分支非常重要?？梢酝耆采w分支開口。缺點(diǎn):由于有多層支架金屬，導(dǎo)絲和球囊再次通過較困難，操作復(fù)雜。25冠脈叉病變介入技巧Geetal.JACC2005;46:613Longtermoutcomeof“Crush”Stentingtechnique26冠脈叉病變介入技巧6monsRRColomboetal.Thecrushtechnique27冠脈叉病變介入技巧Thereversecrushorinternalcrushtechnique28冠脈叉病變介入技巧Thereversecrushorinternalcrushtechnique主要用于臨時分支支架植入provisionalSBstenting.

29冠脈叉病變介入技巧Thereversecrushorinternalcrushtechnique

優(yōu)點(diǎn):可以保證兩條分支的立刻開通，6Fguidingcatheter可以完成操作。缺點(diǎn):由于有多層支架金屬，導(dǎo)絲和球囊再次通過較困難，操作復(fù)雜。30冠脈叉病變介入技巧Thestepcrushtechniquedoublekissing31冠脈叉病變介入技巧Case:Thestepcrushtechnique32冠脈叉病變介入技巧33冠脈叉病變介入技巧Firstkissing34冠脈叉病變介入技巧35冠脈叉病變介入技巧Secondkissing36冠脈叉病變介入技巧Finalresult37冠脈叉病變介入技巧Theinvertedcrushtechnique39冠脈叉病變介入技巧Theinvertedcrushtechnique適用于分支管徑不小于主支的情況。分支支架擠壓crush主支支架。缺點(diǎn):同thestandardcrushtechnique.40冠脈叉病變介入技巧RestenosisinMV=12.2%RestenosisinSB=2%Galassietal.Cath&Cardiovas.Intervn2007;69:976-8341冠脈叉病變介入技巧Theculottesstentingtechnique42冠脈叉病變介入技巧Theculottesstentingtechnique優(yōu)點(diǎn):適合于任何角度的分叉病變，并提供完美的分支開口覆蓋。缺點(diǎn):分叉病變近段雙層支架重疊，金屬密度高。43冠脈叉病變介入技巧NordicBifurcationStudyII-TheNordicStentTechniqueStudy:CrushvsCulottestenting44冠脈叉病變介入技巧NordicBifurcationStudyII-TheNordicStentTechniqueStudy:CrushvsCulottestentingIndividualend-pointat6months45冠脈叉病變介入技巧TheYstentingtechnique46冠脈叉病變介入技巧Theskirttechnique47冠脈叉病變介入技巧TheYstentingtechnique

andTheskirttechnique優(yōu)點(diǎn):這是最后一種治療分叉病變的方法，適用于非常復(fù)雜的分叉病變并要求保證導(dǎo)絲進(jìn)入兩分支。缺點(diǎn):近端支架釋放系統(tǒng)需要改良，手工將支架捻在雙球囊上。應(yīng)用DES易破壞polymer。近端支架很難完全連接遠(yuǎn)端雙支架。采用Y支架技術(shù)時，多數(shù)術(shù)者將分支導(dǎo)絲回撤并放入主支，這時釋放近端支架可以更好連接遠(yuǎn)端支架48冠脈叉病變介入技巧TheYstentingtechnique77casebeingwithbifurcationlesionsreceivedtheYstentingtherapyand6monsfollow-upresults:RR36%,TLR30%。MaillardL,GuerinL,DrieuL,etal.AmJCardiol1998;82:7A–50S49冠脈叉病變介入技巧ClassificationofbifurcationlesionsaccordingtoplaqueburdenA:DukeB:SanbornC:SafianD:LefevreTheVstentingtechniqueThesimultaneouskissingstentstechniqueTheTstentingandmodifiedTstentingtechniqueThecrushtechnique(Thereversecrushtechnique/Thestepcrushtechnique/Theinvertedcrushtechnique)TheculottesstentingtechniqueEachlesionmustbeapproachedtherapeuticallyinthecontextofitsownanatomy.

50冠脈叉病變介入技巧Thanksforyourattention!51冠脈叉病變介入技巧冠脈叉病變介入技巧ClassificationofbifurcationlesionsaccordingtoplaqueburdenA:DukeB:SanbornC:SafianD:Lefevre53冠脈叉病變介入技巧MedinaA.etal.RevEspCardiol.2006;59:183-4ANewClassificationofCoronaryBifurcationLesions-MedinaClassification1,1,11,1,01,0,10,1,11,0,00,1,00,0,1MBDistalMBProximalSB54冠脈叉病變介入技巧一個好還是兩個好？如果選２個，應(yīng)該采取何種策略?策略選擇的根據(jù)簡單化vs復(fù)雜化循證結(jié)果vs個人選擇并發(fā)癥率(especiallyMI/thrombosis)分叉病變介入治療

-關(guān)注熱點(diǎn)55冠脈叉病變介入技巧Stentingforbifurcationlesionsin2007主支放支架，分支臨時決定Stentingthemainvesselwithprovisionalstentingofthesidebranch56冠脈叉病變介入技巧ProvisionalStentingStrategy

If2ndstentisneededforsidebranchfollowingmainvesselstentingModifiedT-stentingReversecrushing Culottestenting 57冠脈叉病變介入技巧分支血管的保護(hù)與放置支架

并非所有分支血管同等重要!

根據(jù)以下情況實(shí)施分支血管保護(hù)和支架植入分支血管大小與分布區(qū)域分支血管開口病變與病變程度分支與主支成角程度58冠脈叉病變介入技巧SidebranchclosureafterPCI59冠脈叉病變介入技巧Side-branchmaybecompromisedfollowingmainvesselstentingPre-treatmentAfterstentingPlaqueshifting(“Snow-plow”)OstialspasmorSide-branchcompromisebystentmaterialDissectionofplaqueatoriginofside-branchDissectionflapatmainarteryobstructingoriginofside-branchAttimes,thesidebranchcouldbecompromisedbythrombustoo60冠脈叉病變介入技巧DifferenttechniquesoftwostentsbyintentiontotreatbifurcationlesionsTheVstentingtechniqueThesimultaneouskissingstentstechniqueTheTstentingandmodifiedTstentingtechniqueThecrushtechnique(Thereversecrushtechnique/Thestepcrushtechnique/Theinvertedcrushtechnique)TheculottesstentingtechniqueTheYstentingtechniqueTheskirttechnique61冠脈叉病變介入技巧TheVstentingtechnique62冠脈叉病變介入技巧Thesimultaneouskissingstentstechnique63冠脈叉病變介入技巧TheVstentingandthesimultaneouskissingstentingtechnique適合于分叉病變位于接近開口的血管近端，例如位于左主干的分叉病變，并且左主干短或無病變。理想夾角<90°。V支架也適合于其他部位的分叉病變，近段無病變或無須支架。

64冠脈叉病變介入技巧TheVstentingandthesimultaneouskissingstentingtechnique優(yōu)點(diǎn):保證不會丟失分支。

對吻技術(shù)時無須re-crossanystent.65冠脈叉病變介入技巧TheVstentingandthesimultaneouskissingstentingtechnique缺點(diǎn):雙支架近端定位較困難；不可避免造成其中一個支架偏心，往往引起agap。66冠脈叉病變介入技巧TheTstentingtechnique67冠脈叉病變介入技巧ThemodifiedTstentingtechnique68冠脈叉病變介入技巧TheTandmodifiedTstentingtechnique優(yōu)點(diǎn):較crush技術(shù)容易完成。缺點(diǎn):大多數(shù)情況下，分支開口不能完全覆蓋。69冠脈叉病變介入技巧ColomboetalCirculation2004;109:1244-1249*Highcross-overratefromStent+BalloontoStent+Stentgroup(22/43,51%)CypherBifurcationStenting(T-stenting)EffectsoftheTstentingtechnique70冠脈叉病變介入技巧RESEARCHbifurcationsubgroupRRofdifferenttechniquesThehighrestenosisrateofTstentingtechniquemayberelatedtotheincompletecoverageofstentingbeinglocatedattheostiumofSB.TanabeK,HoyeA,LemosPA,etal.AmJCardiol,2004,91:115-8EffectsoftheTstentingtechnique71冠脈叉病變介入技巧VstentingvsTstentingSharmaetal.Vstenting:100ProvisionalTstenting:10032%subjectsreceivedCypherstentandRVDwas3.32mm。72冠脈叉病變介入技巧ProvisionalTstenting73冠脈叉病變介入技巧優(yōu)點(diǎn):HigherproceduralsuccessrateLowerexpenseLowercomplicationsLowerre-PCI7monsTLR<15%。Lefevreetal:ProvisionalTstentingisthegoldenstandardtotreatfalsebifurcationlesion(tpye2,3and4a),mostsubjectsonlyneedonestentimplantation。ProvisionalTstenting74冠脈叉病變介入技巧Thecrushtechnique75冠脈叉病變介入技巧Thecrushtechnique優(yōu)點(diǎn):可以保證兩條分支的立刻開通,這點(diǎn)對保護(hù)功能上重要的分支非常重要。可以完全覆蓋分支開口。缺點(diǎn):由于有多層支架金屬，導(dǎo)絲和球囊再次通過較困難，操作復(fù)雜。76冠脈叉病變介入技巧Geetal.JACC2005;46:613Longtermoutcomeof“Crush”Stentingtechnique77冠脈叉病變介入技巧6monsRRColomboetal.Thecrushtechnique78冠脈叉病變介入技巧Thereversecrushorinternalcrushtechnique79冠脈叉病變介入技巧Thereversecrushorinternalcrushtechnique主要用于臨時分支支架植入provisionalSBstenting.

80冠脈叉病變介入技巧Thereversecrushorinternalcrushtechnique

優(yōu)點(diǎn):可以保證兩條分支的立刻開通，6Fguidingcatheter可以完成操作。缺點(diǎn):由于有多層支架金屬，導(dǎo)絲和球囊再次通過較困難，操作復(fù)雜。81冠脈叉病變介入技巧Thestepcrushtechniquedoublekissing82冠脈叉病變介入技巧Case:Thestepcrushtechnique83冠脈叉病變介入技巧84冠脈叉病變介入技巧Firstkissing85冠脈叉病變介入技巧86冠脈叉病變介入技巧Secondkissing87冠脈叉病變介入技巧Finalresult88冠脈叉病變介入技巧Theinvertedcrushtechnique90冠脈叉病變介入技巧Theinvertedcrushtechnique適用于分支管徑不小于主支的情況。分支支架擠壓crush主支支架。缺點(diǎn):同thestandardcrushtechnique.91冠脈叉病變介入技巧RestenosisinMV=12.2%RestenosisinSB=2%Galassietal.Cath&Cardiovas.Intervn2007;69:976-8392冠脈叉病變介入技巧Theculottesstentingtechnique93冠脈叉病變介入技巧Theculottesstentingtechnique優(yōu)點(diǎn):適合于任何角度的分叉病變，并提供完美的分支開口覆蓋。缺點(diǎn):分叉病變近段雙層支架重疊，金屬密度高。94冠脈叉病變介入技巧NordicBifurcationStudyII-TheNordicStentTechniqueStudy:Crushvs