分叉病变介入技巧

Effects of the T stenting technique
30 25
Restenosis (%)
Cypher Bifurcation Stenting ( T-stenting )
28% 21.8% 18.7% 14.2%
Main branch Side branch Overall
T stenting V stenting
19.5%
P =0.007
5.2% 1.5%2.0% ST 9 mons TLR
Provisional T stenting
Provisional T stenting



优点: Higher procedural success rate Lower expense Lower complications Lower re-PCI 7mons TLR < 15%。 Lefevre et al: Provisional T stenting is the golden standard to treat false bifurcation lesion(tpye2, 3 and 4a), most subjects only need one stent implantation。
Stenting for bifurcation lesions in 2007 主支放支架，分支临时决定 Stenting the main vessel with provisional stenting of the side branch
Provisional Stenting Strategy
MB Distal MB Proximal SB
1, 1, 1
1 , 1, 0
1, 0 , 1
0, 1, 1
1, 0, 0
0, 1, 0
0, 0, 1
Medina A. et al. Rev Esp Cardiol. 2006; 59: 183-4
分叉病变介入治疗 - 关注热点

一个好还是两个好？ 如果选２个，应该采取何种策略 ? 策略选择的根据 简单化 vs 复杂化 循证结果 vs 个人选择 并发症率 (especially MI / thrombosis)

The inverted crush technique
The inverted crush technique

适用于分支管径不小于主支的情况。 分支支架挤压crush主支支架。


缺点: 同 the standard crush technique.
Restenosis in MV = 12.2%
Different techniques of two stents by intention to treat bifurcation lesions

The V stenting technique The simultaneous kissing stents technique The T stenting and modified T stenting technique The crush technique(The reverse crush technique/The step crush technique/The inverted crush technique) The culottes stenting technique The Y stenting technique The skirt technique
V stenting vs T stenting
25%

Sharma et al. 20% V stenting:100 Provisional T stenting: 15% 100 10% 32% subjects received 5% Cypher stent and RVD 0% was 3.32mm。

If 2nd stent is needed for side branch following main vessel stenting Modified T-stenting Reverse crushing Culotte stenting
分支血管的保护与放置支架
并非所有分支血管同等重要! 根据以下情况实施分支血管保护和支架植 入 分支血管大小与分布区域 分支血管开口病变与病变程度 分支与主支成角程度

The Y stenting technique

77 case being with bifurcation lesions received the Y stenting therapy and 6 mons follow-up results:RR 36%, TLR 30%。
Dissection of plaque at origin of side-branch
Dissection flap at main artery obstructing origin of side-branch
After stenting At times, the side branch could be compromised by thrombus too
Restenosis in SB = 2%
Galassi et al. Cath & Cardiovas. Intervn 2007; 69: 976-83
The culottes stenting technique
The culottes stenting technique 优点: 适合于任何角度的分叉病变，并提供完美的 分支开口覆盖。
The step crush technique
Case: The step crush technique
First kissing
Second kissing
Final result
The step crush technique

优点: 6F guiding catheter可以完成操作，特别适合于桡动 脉经路，第二次导丝和球囊再次通过较容易成功。 缺点: 同 the standard crush technique.
分叉病变介入技巧
Classification of bifurcation lesions according to plaque burden
A:Duke B:Sanborn C:Safian
D:Lefevre
A New Classification of Coronary Bifurcation Lesions - Medina Classification


缺点:
双支架近端定位较困难；

不可避免造成其中一个支架偏心，往往引起 a gap。
The T stenting technique
The modified T stenting technique
The T and modified T stenting technique


优点: 较crush 技术容易完成。 缺点: 大多数情况下，分支开口不能完全覆盖。

Side branch closure after PCI
Side-branch may be compromised following main vessel stenting
Pre-treatment
Plaque shifting (“Snow-plow”)
Ostial spasm or Side-branch compromise by stent material
20 15 10 5 0
5.7%
4.8%
Stent + Stent
Stent + Balloon
* High cross-over rate from Stent + Balloon to Stent + Stent group (22/43, 51%)
Effects of the T stenting technique
RESEARCH bifurcation subgroup
20% 15% 10% 5% 0% 7.1% 16.7%
others ： Culotte ， kissing stent
T stent
others
RR of different techniques
The 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, 91:115-8
The V stenting techniqu
The simultaneous kissing stents technique
The V stenting and the simultaneous kissing stenting technique 适合于分叉病变位于接近开口的血管近 端，例如位于左主干的分叉病变，并且 左主干短或无病变。理想夹角<90°。 V支架也适合于其他部位的分叉病变， 近段无病变或无须支架。
The crush technique
The crush technique


优点: 可以保证两条分支的立刻开通,这点对保护功能上重要的 分支非常重要。 可以完全覆盖分支开口。 缺点: 由于有多层支架金属，导丝和球囊再次通过较困难，操作 复杂。