3、分叉病变的介入治疗(候静波教授)

枚（09年10月），10年6月因有症状再行冠脉造影
发现为前降支、第一对角支真分叉病变,因冠脉钙
化较重,行IVUS检查后, 过程中造成前降支、对角
支急性闭塞，紧急于前降支植入支架，对角支未能
开通，患者PCI后反复有不稳定心绞痛发生，20天 后来我院。
外院造影结果
外院造影结果
外院PCI过程
外院PCI过程
0.01 0.1
1
10
100
Favors Provisional Favors Two-Stent
Brar et al. EuroIntervention, 2009 (in-press)
Bifurcation Stenting Meta-Analysis
Stent Thrombosis
Pan et al Colombo et al NORDIC Ferenc et al. BBC ONE CACTUS
Bifurcation Stenting Meta-Analysis
Myocardial Infarction
Pan et al Colombo et al NORDIC Ferenc et al. BBC ONE CACTUS
Overall
0.01 0.1
Provisional
Two Stent
Overall
0.01 0.1
Provisional
Two Stent
0.8% 1.7%
Relative Risk (95% CI)
0.56 (0.23-1.51)
P = 0.45
1
10
100
Favors Provisional Favors Two-Stent
Brar et al. EuroIntervention, 2009 (in-press)
Overall
0.01 0.1
Provisional
Two Stent
0.9% 0.7%
Relative Risk (95% CI)
1.12 (0.42-3.02)
P = 0.82
1
10
100
Favors Provisional Favors Two-Stent
Brar et al. EuroIntervention, 2009 (in-press)
TVF due to SB restenosis 2.8% (no angio f-up) NA
C ros s ov er from 1 s tent to 2 s tents 31.0%
Ang iog raphic S B res tenos is
Steigen TK et al. Circulation. 2006;114:1955-1961 Ferenc M et al. Eur Heart J 2008; 29: 2859–2867 Colombo A et al. Circulation. 2009;119:71–78 HildickSmith D et al. Circulation. 2010;121:1235-1243
How Often We Need 2nd Stent after MV Stent? Crossover from 1 Stent to 2 Stents
40.0% 35.0% 30.0% 25.0% 20.0% 15.0% 10.0% 5.0% 0.0% NO R D IC BBK C AC T US B B C O NE 4.3% 9.4% 2.8% 19.2% 18.8% 14.7%
Unfavourable angle: mini crush
F i n a l
True Bifurcation
(significant stenosis on the main and side branches) No Provisional SB stenting No Yes Is SB suitable for stenting? Yes
Side Branch
-1.08 (-2.91- 0.74)
Overall
-20 -10 1 10 20
1.30 (-23.35 - 5.96)
Overall
-20 -10 1 10 20
Favors Provisional Favors Two-Stent
Favors Provisional Favors Two-Stent
试图恢复对角支血流未果
外院PCI过程
外院PCI过程
紧急于前降 支植入2枚
支架后
病例资料
患者因PCI后反复有不稳定心绞痛发生，较以往加
重，20天后来我院。
造影结果
造影结果
治疗策略
患者前降支有轻度重构，对角支闭塞，左冠提供对
角支少量的侧枝循环；
患者临床症状比较明显，但临床检查并无确切的缺
BBC ONE
CACTUS
500
350
PES
SES
9
6
Yes
Yes
–
6
9
6, 12
Brar et al. EuroIntervention, 2009 (in-press)
Bifurcation Stenting Meta-Analysis
Mortality
Pan et al Colombo et al NORDIC Ferenc et al. BBC ONE CACTUS
YES
NO
P value
0.01 0.83 0.02 0.005 0.41 0.03 0.006
13.9 2.47 88.6 1.73 65.5 0.65 83.3
8.87 2.51 71.7 2.33 59.1 0.96 29.3
U n f a v o u r a
bl e
a n g l e
Unfavourable angle
Bifurcation Stenting Meta-Analysis
Target Lesion Revascularization
Pan et al Colombo et al NORDIC Ferenc et al. BBC ONE CACTUS
Overall
0.01 0.1
Provisional
Bifurcation Stenting Meta-Analysis
Main Branch Stenosis
Pan et al Colombo et al NORDIC Ferenc et al. CACTUS
Provisional
Two Stent
4.9% 3.6%
Relative Risk (95% CI)
血证据，是否有进一步PCI，开通对角支的必要？
OCT检查
对角支开口处有 血栓，并无明显 钙化，可看到开 口缝隙
近端支架 贴壁尚可
对角支远段多层 支架
治疗策略
患者对角支血流不充分，且开口提示血栓性
病变，考虑还是上次PCI过程中急性损伤了
对角支开口所致，对角支应该还有打开的可 能，决定尝试PCI。
1.41 (0.76-2.61)
P = 0.27
Overall
0.01 0.1
1
10
100
Favors Provisional Favors Two-Stent
Brar et al. EuroIntervention, 2009 (in-press)
Bifurcation Stenting Meta-Analysis
3.6% 6.8%
Reduction
43%
Relative Risk (95% CI)
0.57 (0.37-0.87)
P = 0.01
1
10 100
Favors Provisional Favors Two-Stent
Brar et al. EuroIntervention, 2009 (in-press)
I N S I D E
II
T r i a l
Pts Randomif Cross-Over to SB Stenting
VARIABLE
QCA Lesion length, mm Reference diameter % DS IVUS MLA, mm2 Plaque burden Remodeling index Calcium (arc >90O ), %
Bifurcation Classification (Medina et al)
Classification
1 or 2 Stents :Randomized Trials
Study Pan et al Colombo et al NORDIC Ferenc et al. No. Pat- Two-stent Type of Thienopyridine ients Strategy DES duration, mo 91 85 413 202 Any Any Any T-stenting Crush or Culotte Crush SES SES SES SES 12 3 6-12 6-12 Intention to Treat Yes No Yes Yes Angio F/U (months) 6 6 8 9 Clincial F/U (months) 11 6 6 12, 24
分叉病变
Background: Bifurcation lesions
15-20 % of lesions treated in the cathlab Still a challenge for interventionalists Lower success rates Higher incidence of procedural complications Higher reintervention rates Ideal strategy of bifurcation lesion treatment is still debated