[基础医学]CTO病变的技巧冠心病最新进展.ppt

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,慢性完全闭塞病变的相关概念慢性完全闭塞病变的病理结构和特点CTO介入的导丝选择CTO病变的支架选择,CTO的定义,闭塞时间大于3个月的病变,CTO病变形成时间的判断,AMI的时间症状加重的时间侧枝循环形成的多少及侧枝的直径,CTO病变长度的判断,顺行显影逆行显影双向造影,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,CTO病变的病理结构,2.细胞外基质：胶原、钙化,CTO病变的病理结构,3.微血管,CTO病变的类型,重度狭窄慢性闭塞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,粥样斑块+钙化慢性发展融合而成,CTO病变的病理特点,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,超滑导丝：如PT Graphic Intermediate、PT2、Shinobi、Cross NT、Whisper等Coil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,超滑导丝,SCIMED PT2,The combination of a polymer cover and hydrophilic coating 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 tip,Terumo CrossNT,WHISPER Redefines Polymer Wire Performance,ResponsEase grind technology,DURASTEEL core material,Polymer Coated/Hydrocoat Distal segment,Soft tip designed for frontline use,HI-TORQUE PILOT Design,HI-TORQUE PILOT Family Product Description,Design Highlights:Polymer-tip,hydrophilic Core-to-tip with moderate support Graduated tip stiffness in the family Modified RESPONSEASE parabolic grind DURASTEEL core material Single lesion measurement marker,The HI-TORQUE PILOT family of guide wires offers a choice of wires that vary in tip stiffness to address a wide variety of lesion morphology.,Tip coils beneath the polymer help facilitate tip shaping.,Modified RESPONSEASE Parabolic GrindThis modified RESPONSEASE design provides additional support,excellent torque transmission and in-lesion tip control.,The HI-TORQUE PILOT guide wires maintained their tip shape better than competitive wires after passing through a tortuous path model.,The DURASTEEL core material of the HI-TORQUE PILOT family is stronger than conventional stainless steel for improved core strength and tip shape retention.DURASTEEL withstands more pulling force than regular 304v stainless steel.,.007”Corewire Support,PTFE 喷涂 近端 黑色的PTFE 袖套延伸至远端头部,平的显影线圈,Shinobi&Shinobi Plus,.010”Corewire support,SHINOBI Plus,SHINOBI,WIZDOM 的核心钢丝,STABILIZER Plus 的核心钢丝,处理CTO病变时常用的导丝,Coil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,ACS导丝,A Guide to ACS HI-TORQUE Guide Wires,Cross IT,Cross IT100-400,Cross IT特性,Smooth Shaft with Fluororesin coating,Jointless Spring Coil,Property of ASAHI NEOS PTCA GUIDEWIRE 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 Wire,Jointless spring coil made of two different metals provides good torqueability and excellent slide property with devices,Medical Grade Silicone Coating,Jointless Spring Coil structure image,Soft/SoftAG141000Radio-opacity 3cmCoil 30 cmDiameter 0.014inchLength175cm,This is a first choice guidewire with high torque response and excellent steerability because of the unique core property.（Tip load 0.7G）,Intermediate/MediumAG142000Radio-opacity 3cmCoil 30 cmDiameter 0.014inchLength175cm,This is a guidewire with a good balance of tip flexibility and support performance.（Tip load 3.0G）,Standard/StandardAG143000Radio-opacity 3cmCoil 30 cmDiameter 0.014inchLength175cm,Improved tip stiffness with our unique core taper design.（Tip load 6.5G）,Light/LightAG145000Radio-opacity 3cmCoil 20cmDiameter 0.014inchLength175cm,ASAHI NEOS PTCA Guide Wire Line-up,Improved lubricity and good tip shape memory with our unique core design.Excellent torque response.This wire has a flexible tip and can be used as a first choice wire for almost all procedures.（Tip load 0.5G）,（Tip load 3.0G）,Miracle4.5/Miraclebros4.5AG14M045Radio-opacity 11cmCoil 11 cmDiameter 0.014inchLength175cm,（Tip load 4.5G）,Miracle6/Miraclebros6AG14M060Radio-opacity 11cmCoil 11 cmDiameter 0.014inchLength175cm,（Tip load 6.0G）,Miracle12/Miraclebros12AG14M070Radio-opacity 11cmCoil 11cmDiameter 0.014inchLength175cm,（Tip load 12.0G）,Miracle3/Miraclebros3AG14M050Radio-opacity 11cmCoil 11cmDiameter 0.014inchLength175cm,Miracle 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.,Structure of Conquest Pro/Pro12,AGH143090 Conquest Pro,Grand Slam/Grand Slam AG141002Radio-opacity 4cmCoil 4cmDiameter 0.014inchLength175cm,In spite of its flexible tip,the core is also designed to provide strong support when approaching the tortuous lesions.（Tip load 0.7G）,Marker WireAG141010Radio-opacity 3cmCoil 30cmDiameter 0.014inchLength175cm,Same 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/ProwaterAG146000Radio-opacity 3cmCoil 20cmDiameter 0.014inchLength175cm,CONQUEST/ConfianzaAG143090Radio-opacity 20cmCoil 20 cmDiameter 0.014inchLength175cm,This 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）,Hydrophilic 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）,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20mm，血管残端程鼠尾状状。,鼠尾状,下列情况首选超滑涂层的导丝,2.闭塞段有弯曲的,闭塞段扭曲,下列情况首选超滑涂层的导丝,3.闭塞段近端及远端弯曲重的,近端过度扭曲,远端过度扭曲,下列情况首选尖端缠绕形导丝,1.血管残端呈齐头的2.闭塞段近端有分支开口的,齐头闭塞,下列情况首选尖端缠绕形导丝,3.闭塞段长度20mm4.闭塞时间6个月,导丝通过闭塞段时的情况,1.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,2.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,1.根据不同的投照角度,如何判断导丝是否在真腔,2.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,3.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,4.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,成形半径大，则前向力被分解，导丝不易前行成形半径大，对血管壁损伤大成形半径大，不易调整方向,闭塞段近端成角大的病变,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,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,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 StudyPrimary 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 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 Conclusion,In this feasibility study the CYPHERTM Sirolimus-eluting stent 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 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-up,Clinical Event(%),20,4,P0.001,24,8,22,8,19,4,3,2,0,P=0.003,P=0.009,P=0.001,P=NS,P=NS,0,6-month Angiographic Follow-up In-Stent,P0.0001,P0.0001,41,36,11,7,%,73%,81%,Angiographic Binary Restenosis Relative Risk Reduction,Conclusions,As 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 groups,PRISON II,Thanks,Q&A,